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TABLE OF CONTENTS

ACRONYMS
OVERVIEW OF FIGURES AND TABLES
PREFACE

PART I

GENERAL CONCEPTS AND PROGRAMMING

HISTORY AS JUSTIFICATION

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THE PROCESS OF TRAUMATISATION

p13

B.1

What is a traumatic event?


B.1.1
The Diagnostic and Statistical Manual (DSM) definition
B.1.2
A transcultural psychiatry approach
B.1.2.1
Mental health and psychosocial health

B.2

Normal reactions to abnormal circumstances: the coping process


B.2.1
When it comes back: re-experiencing (Intrusion)
B.2.2
Let us forget (Avoidance)

B.3

Who is most at risk? (Vulnerability)


B.3.1
Event related risk factors
B.3.2
Person related risk factors
B.3.3
Environment related risk factors

B.4

How people continue to live (Resilience)


B.4.1
Physical
B.4.2
Mental
B.4.3
Social
B.4.4
Spiritual
B.4.5
Moral

CONSEQUENCES OF VIOLENCE
C.1

Physical health
C.1.1
Increased physical complaints
C.1.2
Increased physical health disorders
C.1.3
Increased unhealthy behaviour

C.2

Mental health
C.2.1
Stress and distress
C.2.2
Acute psychiatric disorders
C.2.3
Post-Traumatic Stress Disorder (PTSD)
C.2.4
Other psychiatric co-morbidity
C.2.5
Depression
C.2.6
Generalised anxiety disorder
C.2.7
Chemical abuse/dependency

C.3

Social, spiritual and moral health


C.3.1
Relevance
C.3.2
Social health
C.3.3
Spiritual health
C.3.4
Moral health

C.4

Children
C.4.1
C.4.2
C.4.3
C.4.4
C.4.5
C.4.6

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Justification
General reactions
Infants and toddlers
School children
Adolescents
Reactions within the family

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

TOWARDS A GENERAL FRAMEWORK & POLICY


D.1

Scope of the intervention


D.1.1
Individual care and community support
D.1.2
Focus of intervention
D.1.3
Early intervention

D.2

Objectives
D.2.1
General objectives of mental health projects
D.2.2
General objectives of psychosocial projects

D.3

Package
D.3.1
D.3.2
D.3.3

PART II
E

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of psychosocial activities
Psycho logical package
Social package
Integration and comprehensive medical services

PROGRAMMING DETAILS

INDIVIDUAL TREATMENT AND SUPPORT

p40

E.1
E.2

Acute crisis intervention


Severe psychiatric or psychological mental health conditions: Drug therapy
E.2.1
Consider before prescribing
E.2.1.1
Organic causes
E.2.1.2
Substance abuse
E.2.1.3
Cultural expression
E.2.2
Place and use of drug therapy
E.2.3
Supportive counselling
E.2.4
Drug prescription
E.2.5
Anxiety disorder
E.2.5.1
Isolated anxiety cases
E.2.5.2
Underlying mental disorders
E.2.5.3
Contra-indication
E.2.6
Depression
E.2.6.1
Contra-indication
E.2.7
Post-Traumatic Stress Disorder (PTSD)
E.2.7.1
Contra-indication
E.2.8
Psychosis
E.2.9
Agitation
E.2.10
Insomnia

E.3

Supportive counselling
E.3.1
Psychosocial support in the medical setting
E.3.2
Individual & group counselling

E.4

Children
E.4.1
Basic interventions

INTERVENTIONS AT THE COMMUNITY LEVEL: THE SOCIAL COMPONENT


F.1

Acute emergencies
F.1.1
Practical support: provision of health care and basic materials
F.1.2
Information centre
F.1.3
Group debriefings

F.2

Chronic crises
F.2.1
Practical needs
F.2.2
Community mobilisation
F.2.2
Health education

F.3
F.4

Networking
Distraction activities

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

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INTEGRATION OF SERVICES
G.1

Justification

G.2

Medical staff

G.3

Integrated programming
G.3.1
G.3.2
G.3.2.1
G.3.2.2
G.3.3
G.3.4
G.3.4.1
G.3.4.1.1
G.3.4.1.2
G.3.4.2
G.3.4.3
G.3.4.3.1
G.3.4.3.2
G.3.4.3.3
G.3.4.3.4
G.3.4.4
G.3.4.5
G.3.5
G.3.5.1
G.3.5.2
G.3.5.3
G.3.6
G.3.6.1
G.3.6.2
G.3.6.3

Psychosocial services in basic health care settings


Psychosocial services in nutrition programmes
Therapeutic feeding programme
Supplementary feeding programme
Psychosocial services in tuberculosis (TB) programmes
Mental health and psychosocial services in HIV/AIDS programmes
Justification
Mental health disorders related to HIV/AIDS
Psychosocial problems related to HIV/AIDS infection
Treatment of mental health disorders: counselling and drug therapy
Management of psychosocial problems: role in continuum of care
Voluntary Counselling & Testing (VCT): psychosocial support
Community mobilisation and outreach
Adherence to anti-retroviral (ARV) therapy
Home-based care and end-stage palliative care
Meeting the needs of specific groups and MSF staff
Policy implications
Psychosocial services in projects addressing sexual violence
In all medical programmes
In areas where the prevalence of rape is high
In contexts of mass rape
Psychosocial services in situations of chemical and biological warfare (CBW)
Supportive counselling in threat of CBW
Mental health support in the aftermath of CBW
Staff care

ADVOCACY

PART III

p75

SPECIFIC TOPICS

FIELD ASSESSMENTS
I.1

Justification

I.2

Ethics

I.3

Qualitative and quantitative methods


Assessment instruments
Quantitative instruments
Qualitative instruments
Validation of information
Triangulation of data

Early warning and field assessments


I.4.1
I.4.2

I.5

p78

Assessment approaches and principles


I.3.1
I.3.2
I.3.2.1
I.3.2.2
I.3.3
I.3.4

I.4

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Early indicators
General needs assessment by the field team

In-depth assessments
I.5.1

Problem tree

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

PROJECT PLANNING
J.1
J.2

Mental health and psychosocial care in acute emergencies


J.2.1
J.2.2
J.2.3
J.2.4
J.2.5
J.2.6
J.2.7
J.2.8
J.2.9
J.2.10

J.3

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K.1

Trainers attitude and methodology

K.2

Training about psychosocial support in the medical setting


Training about psychosocial support in the community
K.3.1
K.3.2
K.3.3

Knowledge
Skills and attitude
Community exposure

K.4

Training about counselling

K.5

Clinical supervision

MONITORING AND EVALUATION


L.1
L.2

Principles
Acute emergencies
L.2.1
L.2.2
L.2.3

L.3

Outpatient department (OPD)


Mental health and psychosocial services
Outreach

Chronic crises
L.3.1
L.3.2

Project purpose
Specific objectives
Indicators
Target group
Time perspective
Activities of care
Structure of services
Human resources
Training
Strategic aspects

TRAINING

K.3

Project purpose
Specific objectives
Indicators
Target group
Time perspective
Activities of care
Structure of services
Human resources
Training
Strategic aspects

Psychosocial care in post-crisis / rehabilitation


J.4.1
J.4.2
J.4.3
J.4.4
J.4.5
J.4.6
J.4.7
J.4.8
J.4.9
J.4.10

Project purpose
Specific objectives
Indicators
Target group
Time perspective
Activities of care
Structure of services
Human resources
Training
Strategic aspects

Psychosocial care in chronic crises


J.3.1
J.3.2
J.3.3
J.3.4
J.3.5
J.3.6
J.3.7
J.3.8
J.3.9
J.3.10

J.4

p89

Definitions

Output indicators
Process indicators

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

p106

HUMAN RESOURCES MANAGEMENT


M.1

p110

Recruitment of expatriate and national staff

M.2

Job descriptions

M.3

Staff support

LOGISTICS

p112

DEFINITIONS

p113

INFORMATION RESOURCES - Websites

p120

INDEX REFERENCES

p126

ACRONYMS
AIDS

Acquired Immunodeficiency Syndrome

ARV

Anti-Retroviral therapy

CBW

Chemical & Biological Warfare

DSM

Diagnostic and Statistical Manual of Mental Disorders

FGD

Focus Group Discussion

HIV

Human Immunodeficiency Virus,

MHO

Mental Health Officer

NGO

Non-Governmental Organisation

OPD

Outpatient department

PTSD

Post-Traumatic Stress Disorder

TB

Tuberculosis

VCT

Voluntary Counselling & Testing

OVERVIEW OF TABLES AND GRAPHS


PART I
Table 1

GENERAL CONCEPTS AND PROGRAMMING


Evolving definitions of a traumatic event stated in the DSM

Figure 1 The normal coping process


Figure 2 Vulnerability factors for the normal coping process
Table 2

Examples of vulnerable groups

Figure 3 Resilience factors that influence the normal coping process


Table 3

Examples of factors that support resilience

Figure 4 Overview of consequences of violence


Table 4

Overview of possible physical health complaints after exposure to traumatic events

Table 5

Signs of Stress and Distress

Table 6

Criteria and symptoms of Post-Traumatic Stress Disorder

Table 7

Overview of depression symptoms

Table 8

Overview of symptoms of generalised anxiety disorder

Table 9

Overview of symptoms of substance abuse disorder

Table 10 Overview of symptoms of social, spiritual and moral health problems


Table 11 Overview of expressions of children exposed to traumatic experiences
Figure 5 Mental health continuum
Figure 6 Intervention model for psychosocial projects to address the psychological consquences of violence through individual and
community interventions.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

PART II

PROGRAMMING DETAILS

Table 12 Overview of acute crisis intervention strategies in MSF psychosocial, mental health projects
Table 13 Considerations for prescribing psychotropic drugs
Table 14 Summary of drugs and prescriptions in MSF psychosocial, mental health projects. ALWAYS read accompanying text above
Table 15 Overview of supportive counselling interventions in MSF psychosocial, mental health projects
Table 16 Overview of basic interventions in the management of traumatised children
Table 17 Overview of community mobilisation and health education
Table 18 Overview of social activities
Figure 7 Levels of psychosocial integration in basic health care programmes
Table 19 Overview of psychosocial activities in nutrition programmes
Table 20 Examples of possible psychosocial problems and interventions in TB Projects
Table 21 Overview of common mental health disorders associated with HIV/AIDS
Figure 8 Overview of the links between the tasks of (VCT) counsellors and other services
Table 22 Qualifications, roles and responsibilities of (VCT) counsellors
Table 23 Psychosocial support after sexual violence
Table 24 Neuropsychiatric syndromes or symptoms in biological agents
Table 25 Management and staff considerations for mental health interventions in populations affected by chemical and biological warfare
Table 26 General directions on advocacy in psychosocial/mental health programmes

PART III

SPECIFIC TOPICS

Table 27 General characteristics of an MSF psychosocial assessment


Table 28 Overview of assessments, methods and instruments
Table 29 Criteria of good quality for assessments in chronic crises
Figure 9 Overview of assessment topics and phases
Table 30 Overview of factors important for early assessment and monitoring of psychosocial needs
Table 31 Overview of factors important for an in-depth assessment of psychosocial needs
Table 32 Summary of essential features of a mental health and psychosocial intervention in an acute emergency
Table 33 Summary of essential features of a psychosocial intervention in chronic crises
Table 34 Summary of essential features of a psychosocial intervention in Post-Crisis/Rehabilitation
Table 35 Overview of psychosocial training curricula
Table 36 Overview of a monitoring system in acute emergency psychosocial care
Table 37 Overview of a monitoring system for psychosocial care projects in chronic crises
Table 38 Criteria for staff recruitment
Table 39 Some signs of burnout
Table 40 Elements of staff support

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

PREFACE
Mdecins Sans Frontires (MSF) started mental health and psychosocial interventions in 1990
with a community based programme in Gaza (Palestine). Since the early nineties MSF has
implemented psychosocial or mental health interventions in over 40 countries in nearly all
continents (except Australia).The interventions covered various aspects of mental health:
psychiatric patients in institutions, psychiatric care in acute emergencies, people suffering from
(acute) trauma, adaptation and chronic stress related psychological complaints, and
psychosocial support for individuals and groups to improve the efficacy of nutrition,TB and
HIV programmes.
As an emergency medical humanitarian organisation the bulk of our programming is in acute
or chronic settings of mass conflict. A situation of mass violence is characterized by events that
include a great number of people (thousands rather then hundreds) who have experienced,
witnessed or heard of traumatic events. Often there is significant material damage, destruction
of the social fabric and functioning of the community.
The Guidelines focus on man-made disasters rather than on natural disasters. It was not for
reasons of priority setting nor interest that this choice was made. We have gained more
experience in the field of man-made disasters. Despite the differences between these two
types of tragedies, our experiences in India and El Salvador (both earthquake interventions)
showed that the principles described in these Guidelines also work very well in contexts of
natural disasters.
Humanitarian workers have the moral obligation to share their technical experiences with
others to avoid repeating the same mistakes.These guidelines were written for this reason.
We do not claim that our intervention model is the only way to approach psychosocial or
mental health problems in areas of conflict. We realize the limitations and opportunities of
our organisations specific medical, humanitarian emergency origin as well as the specificity
of our experiences.
The manual is useful for people in co-ordinating positions (medical and programme
management) to strategize, to plan, to supervise, and to coach a psychosocial or mental health
programme component.
The manual is easily accessible for lay people and others interested in the theoretical
background and workings of conflict related psychological programme interventions.
Mental health professionals and medical staff with less experience in emergency psychosocial
programming may also profit from the manual in their preparation for field programmes.
The Guidelines are not intended to be a handbook for counselling or psychotherapy. It does not
contain detailed treatment protocols and specialised interventions because the mental health
specialist in the programme is supposed to have this knowledge and skills before departure.
Furthermore, cultural differences do not favour a standardised approach to protocols.
The set up of the guidelines helps people to find quick answers for their questions.Tables at
the end of each section summarize the most important issues. A table of contents including
an overview of tables and graphs are found at the start of the document.To improve
understanding a list of acronyms is available.
To augment understanding, technical specialist language is avoided as much as possible.
If special terminology is used a definition is available in one of the last chapters of the
guideline, see Chapter O.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

The information in the guidelines is clustered around three themes:


Part I

GENERAL CONCEPTS AND PROGRAMMING


The purpose of Part I is to answer the many questions regarding mental
health and psychosocial programming from a theoretical perspective.
General concepts about trauma, and its consequences on various aspects of
health are examined from a theoretical perspective.The rationale behind
psychosocial and mental health programmes is discussed and a model of
intervention introduced.

Part II

PROGRAMMING DETAILS
The components of a psychosocial intervention: individual treatment and
group support are described in this section. MSF focuses its psychosocial
programmes on the general population.Therefore, the guidelines do not
contain a section on specific programmes for children.
Mental and physical health are regarded as inseparable. How to realise a
combined approach is dealt with in the chapter on integration. Examples are
given for nutrition, sexual violence, chemical and biological warfare. MSF also
deals with chronic diseases like tuberculosis and HIV/AIDS in areas of conflict.
The psychosocial support offered to people suffering from these chronic
disorders is included in the manual.
Health workers in settings of conflict bear witness to a lot of suffering. An
essential element of our mission is to speak out on what they see.
Opportunities for and limitations on advocacy are discussed in this part on
programming details.

Part III

SPECIFIC TOPICS
The guidelines finish with a detailed description of specific topics like
assessment, programme planning, monitoring/evaluation but also training and
human resource management.

To facilitate accessibility to these guidelines they are put on the MSF Holland website at
http://www.artsenzondergrenzen.nl
They are regularly updated to ensure adequate programming. Comments are welcome and
can be sent to Kaz.de.Jong@amsterdam.msf.org
The process of writing these guidelines has been lengthy because the support to people
implementing these programmes always prevailed and the growing number of programmes
made available time scarcer. Despite reflecting over ten years of field experience these
guidelines are only one step in the process of developing psychosocial and mental health
interventions in non-Western settings.The theoretical knowledge of trauma and experience in
programming is progressing rapidly.
Today there is more conflict than in any other time in history. At the same time we are
learning more about perspectives from other cultures. It is our duty to use the newly acquired
insights to increase understanding, to augment compassion and to reduce conflict.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

I would like to thank the following people:


Our national staff all over the world, both counsellors and support staff in our past and
present programmes.Though they have been often traumatized themselves the choice to help
their own local people deal with similar experiences is brave.They have been the key factor to
the success of many of our programmes. Without their patience and persistence we would
never have succeeded.
All the mental health and other MSF expats, like the trainers, who left their convenient
practices, interesting salaries and promising job perspectives to help others.They have fought
the battle on the frontlines, realizing services that enabled local people to help their own
communities; to help the victims change into survivors.
Main contributors to these Guidelines:
Ideas and editing . . . . . . . . . . . . . . . . . . . . Sue Prosser, Lucie Blok, Riekje Elema
Theoretical backgrounds in part 1 . . . . . Pim Scholte, Rolf Kleber, Sue Prosser
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . Alison Swan, Sue Prosser
Health & community education . . . . . . . Ashley Shearer, Maureen Mulhern
Integration . . . . . . . . . . . . . . . . . . . . . . . . . Jose Bastos, Lucie Blok
Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . Saskia van de Kam
Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . Richard van Oosten
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . Tanja Spehr,Victorio Feced, Diane Vidalies
Sexual violence . . . . . . . . . . . . . . . . . . . . . Helen ONeill, Riekje Elema, Katrien Coppens
Training . . . . . . . . . . . . . . . . . . . . . . . . . . . Guus van der Veer, Marleen Diekman, Sue Prosser
Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . Pim Scholte, Rolf Kleber, Loan Lie, Maureen Mulhern
Human resources . . . . . . . . . . . . . . . . . . . Sue Prosser
Anthropological perspectives . . . . . . . . . Pim Scholte, Riekje Elema, Aranka Enema, Sue Prosser
Editing . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aranka Enema, Anna Turville, Polly Markandya
Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chris Winter
Special thanks to Lucie Blok, Marleen Diekman, Riekje Elema, Rolf Kleber, Sue Prosser,
Pim Scholte and Guus van der Veer for always being a source of inspiration and support.
They advocated and helped to realize the psychosocial and mental health perspective in
a medical, emergency organisation.
Lastly, Id like to thank Moniek, Stella and Issa for enduring my regular mental and physical
absence in the past years and helping me to keep the balance in this beautiful and crazy world.
July 2005,
Kaz de Jong

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

PART I
GENERAL CONCEPTS
& PROGRAMMING

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

11

HISTORY AS JUSTIFICATION
Humans have experienced adverse psychological consequences from war throughout history.
A systematic study of the psychological effects of war began in the late nineteenth century.
However it was not until 1980 that a specific type of psychological suffering caused by mass
violence received official recognition. It was at this time that the internationally respected
Diagnostic and Statistical Manual of Mental Disorders III (DSM III) ascribed a unique psychiatric
diagnostic label to the phenomenon called Post-Traumatic Stress Disorder (PTSD).1
The creation of a new diagnostic label implied that a generalised pattern of reactions to
extreme events had been recognised. Under this new comprehension, psychological suffering
following traumatic experiences was no longer explained by an individuals weakness or
malingering,2 but by a series of predictable and measurable mental health and psychosocial
effects.
Since its acknowledgement, PTSD has become a popular area of psychiatric research. PTSD has
especially captivated researchers because it is considered one of the only psychiatric disorders
whose unique cause is an external event.3 In the decade following its discovery, research about
PTSD contributed significantly to Western researchers understandings about the relationship
between external stimuli and internal psychological processes.4 However, it also led to an
overemphasis on PTSD as the sole reaction to (mass) violence.
It was not until the mid 1990s that research interests surrounding the consequences of (mass)
violence broadened to include studies of how social, cultural, moral and spiritual environments
influence individual and group responses to trauma.
The following practical guidelines often refer to traumatic stress and PTSD. It must be noted,
however, that none of the contributors regards traumatic stress or PTSD as the sole reaction to
(mass) violence.The daily reality in the field of humanitarian assistance confronts us with the
pervasive destruction of all aspects of human health (physical, mental, social, spiritual and moral).
To save lives, and to improve the functionality and dignity of people who have experienced mass
violence, all these aspects need attention.The proposed intervention model is based on a
comprehensive view of human suffering after mass violence.

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

B
B.1

THE PROCESS OF TRAUMATISATION


What is a traumatic event?
Traumatic experiences and confrontation with extreme events are not new or recent
phenomena. In fact they are quite common.5 From pre-historic times, humans have developed
well functioning stress appraisal and adaptation mechanisms. General theories like flight, fight and
fright reactions6 and general adaptation system7 have been proposed about how humans
physically and mentally cope with stress. However, a traumatic event is different to a stressful
event.The biology of acute traumatic stress reactions is different to the biology of other general
stress responses.Traumatic stress is caused by the confrontation with helplessness and death,
a complete loss of control.8 For someone who has experienced trauma, life seems to have lost
its meaning and predictability.This hampers the critical process of survival and adaptation.9
It requires more complex process than just adaptation and coping: acceptance of what
happened, the recognition that life is never the same again, giving meaning and developing new
future perspectives.

B1.1

The Diagnostic and Statistical Manual (DSM) definition


The definition of a traumatic event has undergone constant change since its acknowledgement
in the Diagnostic and Statistical Manual of Mental Disorders III (DSM III),10 see Table 1. The
modifications in definition reflect growing developments in research.

Tbl. 1 Evolving definitions of a traumatic event stated in the DSM11


Diagnostic system Definition of Traumatic Event

Year

DSM III

Evokes significant symptoms of distress in almost everyone

1980

DSM III-R

Event outside the range of normal experience and distressing to everyone

1987

DSM IV (-TR)

Event that involved actual or threatened death or serious injury, or a threat to


physical integrity of self or others, provoking intense fear, helplessness or horror

1994
(2001)

Examples of
traumatic eventsi
(single/ accumulated)

Self experienced

Witnessed/heard

Getting wounded
Being threatened with death
Being subjected to gross human rights violations
Significant loss (of people or property)
Confrontation with actual fighting
(crossfire, bombardment, shelling)

Torture
Sexual violence
Killing (strangers or loved ones)
Dead bodies, mutilations, severely wounded
Stories of traumatic experiences

For the purpose of discussing the consequences of mass violence in the context of humanitarian
assistance, the definition of a traumatic event found in the DSM IV-TR (Diagnostic and Statistical
Manual of Mental Disorders IV Text Revised)12 will be used.

i This is just a selection and not intended to include all types of traumatic experience.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

13

B.1.2

A Transcultural Psychiatry Approach


While the DSM has noted a patterning, or typology, in certain disease processes, it is incapable
of identifying cross-cultural definitions and expressions of illness. In particular, it does not
consider how certain environmental factors such as social, political, economical, spiritual, or
moral13 affect peoples definition of trauma,14 their experience of trauma,15 and their symptomatic
expression of it.16
Contemporary approaches to mental disorder recognise that a system of classification only
becomes relevant when the context and identities of the people involved are taken into
consideration.17 ii Transcultural psychiatry offers a useful and complementary approach to the
DSM for defining PTSD in international settings. It seeks to combine anthropological information
about culture and social groups with epidemiological and psychiatric studies of the aetiology of
health and illness.Transcultural psychiatry employs the anthropological assumption that patterns
of thought and behaviour are learned through ones cultural environment.Therefore while
people experience the same types of psychiatric and psychological disorders worldwide, they
experience and express these conditions in varying ways cross-culturally. As a consequence
psychiatry cannot always identify mental disorders through Western categories of pathology.18
This is particularly the case with culture-bound syndromes, where mental and psychosocial
disorders are defined by local patterns of behaviour that do not fit Western classifications.

B.1.2.1 Mental health and psychosocial health


Implicit in the transcultural psychiatric approach to mental disorder is a distinction between
disease and illness. Disease is understood as a condition that is objectively measurable by
diagnostic tools by a practitioner; it can be attributed a diagnostic label through Western clinical
symptomology like the DSM. Illness is defined as a culturally specific expression of distress. It is
the lived experience of the client and his subjective interpretation of his health. Illness as such
cannot be understood through Western medical diagnostic systems, but must be interpreted
within the social, political, economical, spiritual and moral worldview of the client.19 Under this
transcultural psychiatric model, clients suffer from illnesses, while physicians diagnose and treat
diseases.20
In the context of humanitarian assistance the distinction between disease and illness is translated
into a distinction between mental health and psychosocial health. Mental disorders, like disease,
can be measured by objectively verifiable indicators as described in the DSM.Treatment thus
seeks to restore mental health through conventional Western psychological approaches.
Psychosocial disorders are often culture-bound expressions of mental, physical, social, moral or
spiritual states of suffering.21iii Psychosocial treatment aims to reconnect a clientiv to his
environment, community and culture.

ii Several disciplines in mental health have emerged over the last few decades that take this into consideration including: cultural psychology, which has
as its basis the notion that no socio-cultural environment exists or has identity independent of the way human beings seize meanings from it; crosscultural psychology which focuses on performance differences between ethnic groups; psychological anthropology which examines psychological
functioning in socio-cultural contexts; ethno psychology which investigates indigenous or local conceptions of mind, self, body and person.
iii Transcultural psychiatry recognises three types of abnormal behaviour and cognition: those considered abnormal in the West, but normal in other
societies; those perceived as normal in the West, but abnormal elsewhere; and those that occur in exclusive socio-cultural environments (i.e. culturebound syndromes). By identifying a set of symptoms as being abnormal from a Western or non-Western perspective it is possible to ascribe an
accurate (Western) psychiatric label to non-Western expressions (symptoms) of illness.
iv Client refers to a beneficiary who has been admitted into a mental health or psychosocial programme to receive care, and is involved in a therapeutic
relationship with a counsellor/mental health practitioner. The client is not called patient (as in the medical setting) because psychosocial or mental
health support is not necessarily restricted to medical disorders.

14

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

MSF believes a combined mental health and psychosocial health care approach is necessary
to effectively assist survivors of trauma. By employing Western medical approaches to mental
health, as well as local definitions and perceptions of psychosocial health, MSF aims to restore
the functioning and dignity of survivors of traumatic experiences.
B.2

Normal reactions to abnormal circumstances: the coping process


People develop assumptions and expectations about the world they live in throughout their
lives.22 These are often influenced by upbringing, personal life experiences, personality, cultural
norms and individual belief systems.The experience of trauma confronts survivors with
information that is generally inconsistent with their pre-conceptions of the world. In order
to heal from this experience, this new information must be processed until the traumatic
experience is assimilated and integrated into a new or existing worldview.This process is called
the coping process.23 It is considered a normal process experienced by everyone exposed to
traumatic experiences.24
The way in which people cope with their traumatic experiences depends on the culture and
their personality. However, each survivor is confronted with two psychological mechanisms
during the coping process: intrusion and avoidance.25
Despite its normality it should not be overlooked that the emotions belonging to the coping
process are acknowledged and processed.The normality of the reactions should not imply that
the psychological process of working through the emotions of helplessness and anger are
postponed for better times.26

Fig. 1

The normal coping process 27

Frightening,
overwhelming
Traumatic
event

Avoidance

Integration

Intrusion

Not coped

Processing
Disruption to
model of
the world

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B.2.1 It comes back: re-experiencing (Intrusion)


Intrusion is the state in which the survivor unconsciously re-lives his traumatic experience.
Although this confrontation is painful and accompanied by distressing symptoms like nightmares,
flashbacks etc, intrusion enables a survivor to re-evaluate and re-define, and ultimately recover.
Through re-experiencing a traumatic event, survivors regain a sense of control over their
environment.They learn to comprehend their traumatic experience in a different light, and
ascribe new meaning to it.Traumatic stimulus and response-relationships are weakened; the
world becomes predictable again; and a sense of invulnerability is restored.
Sometimes however intrusive experiences create such a high state of arousal that an individual
begins to escape or block out traumatic memories. In this case the processing of the traumatic
experience does not occur effectively, and intrusive memories continue to cause the survivor
agony.This explains why some people can continue to experience intrusive memories for many
years without recovery.28
The re-experiencing of the event can also happen consciously, for instance when people share
their experiences with friends and family, or when they discuss their experiences under
professional therapy.This is not intrusive because the individual is making a conscious effort to
recall the trauma.The controlled self-exposure is less likely to result in avoidance.
B.2.2 Let us forget (Avoidance)
In an effort to cope with feelings of discomfort provoked by the traumatic experience and
intrusions, a survivor will often avoid thinking about the event. Different ways of avoiding
thoughts, feelings, and sensations associated with trauma can include:
Actively avoiding trauma-related thoughts and memories
Physically staying away from trauma reminders (e.g. conversations, places)
Forgetting important aspects of the trauma (amnesia)
Shutting down emotionally (emotional numbing)
Interpreting ones surrounding as strange or unreal (de-realisation)
Feeling strange, not oneself or disconnected from ones surroundings (depersonalisation)
Avoiding or forgetting painful memories is a normal and healthy element of the coping process;
however, if it becomes a fixed reaction, avoidance can hinder recovery.
When a person blocks the necessary re-evaluation of a traumatic event, stimulus and responserelationships cannot be weakened. Symptoms will persist because the traumatic experience
remains dormant instead of integrated. Ultimately the survivor will not recover.29
During therapeutic intervention, survivors must be allowed to control the speed and level of
exposure of their intrusive memories. External force to relive the traumatic memories is
counter-productive. It will reinforce avoidance, induce fear and subsequently hinder integration
and adaptation.

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B.3

Who is most at risk? (Vulnerability)


Any conceptualisation of sickness, but particularly psychiatric illness, involves certain assumptions
about the individual self and its relationship to shared community beliefs and behaviour.
Traumatic events are felt and expressed differently across cultures and sometimes even within
the same culture.The intensity of a traumatic experience can therefore not be compared
between individuals. Generalisations about risk factors associated with trauma need careful
consideration because they may result in value judgments about particular groups or individuals.
Vulnerability is understood here as influenced by multiple factors: previous life events, personal
attributes and the recovery environment.

Fig. 2

Vulnerability factors for the normal coping process

Vulnerability
Event related (e.g. intensity, life danger, extent of physical injury,
number of experiences, duration, proximity, preparation)
Personal (pre-trauma coping style, psychiatric disorders)
Recovery environment (socio-economic, poverty, marginalisation)

Traumatic
event(s)

Avoidance

Integration

Coping process

Intrusion

Not coped

B.3.1 Event related risk factors


Extensive Western literature, and some non-Western literature,30 has been published about the
relationship between psychosocial problems or mental health disorders and events-related
vulnerability. Several aspects of the traumatic event have been hypothesized to adversely impact
survivors coping processes, including:
Feelings of personal danger associated with the trauma;31
Physical injury during the experience;32
Duration and frequency of the traumatic event;33
Proximity to the event, including self-experience, witnessing (especially of loved ones being killed
or tortured) and listening to stories as, for instance, counsellors, translators and health workers do.34
Examples of event related vulnerable groups are: war wounded, victims of sexual violence, ethnic
minorities, people who experienced (or witnessed) gross human rights violations.
By nature and definition, a traumatic event is sudden and unexpected. However, the threat may
have been present for years (e.g. refugees waiting for relocation). Anticipation is believed to
dampen the traumatic effects because it reduces uncertainty, and increases a sense of control.35

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B.3.2 Person related risk factors


In addition to event related factors, certain personal factors have been shown to negatively
influence survivors abilities to cope with trauma.These include:
Family history of psychiatric illness36
Past history of treatment for psychological disorder37
Family history of anti-social behaviour38
Childhood history of abuse39
Previous exposure to traumatic events40
In addition to these pre-trauma factors, an individuals ability to cope with a traumatic event can
be influenced by the coping style used during the actual traumatic event and the first stages of
the coping process:
Problem-focused coping is where a person channels hisv resources to solve the stress-creating
problem. Problem focused coping is associated with lower likelihood of PTSD.41
The opposite is emotion-focused coping.The tension aroused by the threat is reduced
through intra-psychic activity, such as denying or changing ones attitude toward the
threatening circumstances.This coping style can be a useful technique for reducing stress in
circumstances where a survivor had no control about the outcome of the event (e.g. torture,
abduction).
Dissociation is a disruption of cognitive functions that are usually integrated, such as
consciousness, memory, identity, or perception of the environment.42
Freezing43
Stupor
Examples of person-related vulnerable groups are: psychiatric and psychological clients or
individuals with immediate post-trauma reactions such as: shock, freezing, dissociation, or
lethargic/submissive coping styles.
B.3.3 Environment related risk factors
The socio-economic, physical conditions and political atmosphere that survivors are surrounded
by while trying to recover has also been shown to affect the ability to cope. Subjective
perceptions of those environments play an equally powerful role in determining how effectively
survivors cope with their traumatic experiences:
Poor socio-economic situation44
Marginalisation in the community45
Length of time spent in refugee or internally displaced camps46
Community denial of traumatic past or events
Examples of environment related vulnerable groups are: orphans, children alone, the physically
disabled, widows, single mother households and the elderly.

v In the manual the male form is used for reasons of convenience. Every male version used in relation to expatriates, national staff, clients or
beneficiaries can also be read as female.

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Tbl. 2 Examples of vulnerable groups


Event related

Person related

Environment related

War wounded

Individuals with history of mental


health problems

Orphans

Individuals who exhibit dissociation,


shock, freezing, stupor and/or
lethargic/submissive coping styles

Physically disabled

People with previous traumatic


experiences

Single mothers

Victims of sexual violence


Ethnic minorities
Survivors (experienced or witnessed)
of human rights violations

B.4

Children alone
Widows

How people continue to live (Resilience)


Resilience refers to an individual or groups capacity to restore a new balance and related
worldview when the old one has become dysfunctional due to confrontation with a traumatic
event.Therapeutic models emphasize the need to identify (and eliminate) the factors that hinder
peoples capacity to restore a worldview.47 Resilience has become an important concept in
emergency psychosocial programmes since it is directly related to mechanisms of self-help and
the restoration of self-control.Traditional medical models that use concepts like symptom
reduction or healing, may not be fully applicable to the treatment of traumatic experiences in
humanitarian crises for several reasons:
The experiences of many beneficiaries in humanitarian crisis contexts are ongoing; therefore it
is more realistic to focus on coping and self-control mechanisms.
The focus on symptom reduction in psychosocial programmes tends to neglect a
comprehensive view of human health.
The following paragraphs will highlight how resilience factors influence the normal coping process
on all levels of human health: physical, mental, social, spiritual and moral, see also Figure 3.

Fig. 3

Resilience factors that influence the normal coping process

Vulnerability

Resilience

Event related,
Personal,
Recovery environment

Traumatic
event(s)

Physical, Mental, Social,


Spiritual, Moral part

Avoidance

Integration

Coping process

Intrusion

Not coped

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B.4.1 Physical
Survivors of trauma often have many basic, practical problems.Those who have sufficient food
and water, good physical health and adequate housing have less stressors and are subsequently
in a more favourable position to cope with their psychological problems. It is important in
psychosocial programmes to address the basic, practical problems, since this would directly
improve resilience.

B.4.2 Mental
Approximately 80% of people in Western settings are able to cope with their traumatic
experiences without external support.48 Normal psychological coping mechanisms are sufficient for
most people under normal conditions in relatively stable contexts.The sooner the coping process
starts the higher the likelihood of positive outcomes.The coping process is promoted through a
relative sense of security, feelings of self-control, self-help and predictability of the environment.49
B.4.3 Social
Social support affects health by mediating the adverse effects of environmental, social, and
internal stressors.50 Social support is multi-factorial and consists of subjective appraisal of support,
supportive behaviour (e.g. participation in organisations), and the company of family and friends.
Participation in group activities also has a strong effect on physical health and functioning.51
A positive social recovery environment in the community for instance expressed through the
caring capacity, acceptance of vulnerable people, presence of a social order, clarity of and respect
for cultural and community roles, promotes resilience because it enhances control, predictability
and self-help. It fosters a sense of belonging.
Parallel to having access to social support resources the ability to mobilise and sustain them is
equally important.52
The positive effect of social support on the resilience of survivors of violence is likely to be
universal.53 However, social support is not always a resilience factor. In some populations, a large
social network made up of many family members may cause a higher level of stress.54
B.4.4 Spiritual
Western medicine, through its technological interest in the how has left individuals with chronic
or serious illnesses little help in answering the question why me?55 The healing process after a
traumatic experience in many cultures is not regarded as a simple medical solution to
psychosocial problem or mental health disorder.Traumatic experiences can lead to a major shift
in the individuals internal belief systems.They can become powerful sources of motivation for
some individuals leading to abstinence from all violence; for others they can become destructive
resulting in a obsession with revenge on perpetrators.56
Many cultures have strong beliefs in fate: the punishment of God as a divine intervention,
suffering to repay karmic debt,57 are examples. Performing rituals (especially burial) and visiting
places of contemplation or worship are powerful tools to promote spiritual health.58 The
importance of spiritual beliefs in mental and physical healing processes is increasingly receiving
attention among mental health researchers.

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B.4.5 Moral
Moral values can play an important role in coping with adverse psychosocial effects of mass
violence, since they can provide a higher meaning or motivation (e.g. fighting for your country,
surviving to tell others, continue for the sake of the children etc.).59
Sometimes moral values are used to confirm self-control: for example, when ones own moral
values are kept and put above those of the perpetrator (e.g. what happens to me, I will not do
to others).These values can constitute important resilience factors but when they fail they may
also cause significant problems such as guilt and shame.
Tbl. 3

Examples of factors that support resilience


Physical

Access to food, water, shelter


Good physical health
Healthy behaviour
Physical activity

Mental

Feelings of control
Previous methods of coping used
Access to knowledge/ information
Access to training/ preparation

Moral

Ability to forgive, show compassion


Recognition of rules/ regulations
Adherence to a moral code
(social, religious)
Sense of contribution to a greater good
Sense of survival for a higher purpose

Spiritual

Religious or spiritual belief


Beliefs about the event
Rituals (e.g. burial)
Places of contemplation, worship

Social

Ability to mobilise social support


Presence of a cohesive community (e.g. caring capacity)
Continuation of traditional activities/festivities
Presence of respected leaders in the community
Existence of social structure/ order
Individual and household security (e.g. safe living environment, freedom of movement)
Self control (e.g. income generation, authority of significant leaders)
Self initiative (e.g. with regard to camp/shelter organisation)

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CONSEQUENCES OF VIOLENCE
Psychological consequences of violence can manifest themselves on all levels of human
functioning: physical, mental, social, spiritual and moral.

Fig. 4

Overview of consequences of violence


Vulnerability

Resilience

Event related,
Personal,
Recovery environment

Traumatic
event(s)

Physical
Mental
Social
Spiritual
Moral

C.1

Physical, Mental, Social,


Spiritual, Moral part

Avoidance

Integration

Intrusion

Failure
to cope

Coping process

increased health complaints, disorders and unhealthy behaviour


stress, psychosis, PTSD, depression, anxiety disorder, substance abuse
poor family life, social networks, withdrawal
spiritual crisis, religious devotees, loss of rituals
survivor guilt, shame, revenge thinking, lack of respect

Physical Health
People with mental health or psychosocial problems rarely visit mental health services.60
Stigmatisation and fear of coming forward are not the only explanations. Often people do
not understand the relationship between their physical complaints and mental suffering.61
Furthermore, people have difficulty articulating their emotional states and use bodily symptoms
to communicate their distress (somatisation).62
Clinicians have developed methods such as symptom checklists to identify people who suffer
from mental health disorders. Both research and field experience shows that PTSD is often
difficult to identify in basic health care settings.Taking a comprehensive view of health as well as
close cooperation between different health services may improve this.The involvement of
structures outside the spectrum of medical services like community centres may further
improve the identification of vulnerable people.63

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C.1.1 Increased physical complaints


Chronic stress, exposure to traumatic events and/or mental health disorders are associated with
many physical health complaints.64 Whether these complaints such as body pains, or headaches
are functional or the consequence of stress induced disorders like cardiovascular diseases can
only be established through physical examination by medical staff.
C.1.2 Increased physical health disorders
In the long term, traumatic experiences lead to increased physical health disorders: more chronic
medical conditions65 (controlling for age, gender, social class, psychiatric illness66), increased visits
to health care facilities (15-25%),67 greater functional disability, and more distressing physical
symptoms.Traumatic exposure is also associated with increased morbidity68 and mortality.69
C.1.3 Increased unhealthy behaviour
The relation between exposure to traumatic events and unhealthy behaviour like cigarette
smoking, alcohol, drugs or high-risk behaviour including dangerous sexual relationships has been
well established.70
Tbl. 4

C.2

Overview of possible physical health complaints after exposure to traumatic events


Physical

Health Consequences

Increased complaints

High blood pressure


Palpitations
Cardiovascular problems
Gastro-intestinal complaints
Headaches
Skin problems
Respiratory problems (e.g. short breath, hyperventilation)
Muscolo-skeletal problems
Generalised body pains
Nervousness (anxiety)
Exhaustion
Sleeping problems

Increased disorders

Chronic medical conditions


Peptic ulcers
Functional medical disabilities
Elevated morbidity of common health disorders
Birth mortality

Unhealthy behaviour

Over consumption of cigarettes, alcohol, drugs


Engaging in risky health behaviour (fighting, dangerous sexual relationships,
sensation seeking)

Mental Health
The importance of culture in the diagnosis of mental health disorders is the focus of intensive
debate among mental health professionals.The current diagnostic system of mental health
disorders (DSM IV-Text Revised)71 has its shortcomings when used in non-Western settings.
Despite these limitations and in the absence of useful alternatives the (Western) diagnostic
system is used in this chapter.

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C.2.1. Stress and distress


Stress is a neurobiological reaction that facilitates the adaptation of the person to external
demands. Stress reactions can be caused by pleasant and unpleasant events. In the latter case,
stress increases attention and reactivity to perceived or potentially dangerous situations.Three
stages of stress can be distinguished: the alarm phase, the reaction phase, and the exhaustion
phase.72 Stress can initially improve performance; but after a certain level and amount of time
functioning and health become negatively affected. It is at this point that stress becomes distress.
Thirty-one signs of stress or distress are currently recognised by the DSM IV-TR,73 see Table 5.
Some ways of expressing stress and distress are influenced by culture. However, most are similar
across cultures.
Reactions of stress and distress are normal in all contexts of mass violence. Despite their
normality, attention must be paid to stress and distress since prolonged states of either can
cause physical and mental damage.74
Tbl. 5

Signs of Stress and Distress75


Cognitive/Emotional

Physical

Behavioural

Excessive sweating
Hyperventilation
Tachycardia
Dry mouth
Dizziness
Extreme tiredness
Frequent urge to urinate
Diarrhoea, vomiting
Migraine
Menstrual problems
Pain in the neck or back

Impulsive behaviour
Strong impulse to cry or run away
Inappropriate behaviour (eg: aggression,
prima donna behaviour)
Startle responses
Shaking or tics
Giggling or unstoppable laughing
Sleeplessness or nightmares
Hyperkinesias
Lack of appetite or excessive eating
Increased substance abuse (eg: smoking, drinking, drugs)
Neurotic behaviour

Lack of concentration
Excitation or depression
Nervousness (tensed)
Emotional instability
Feelings of detachment, weakness
Feelings of being hunted

C.2.2 Acute psychiatric disorders


Adjustment disorder, delirium, mania/hypomania, psychosis, sleep disorders and shock can be the
result of traumatic experiences.76 Other relevant psychiatric disorders are described below.vi
C.2.3 Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder (PTSD) is frequently referred to in connection with traumatic
events.77 The concept, included in both the DSM and the International Classification of Diseases
(ICD-10) of the World Health Organisation,78 is appropriate for describing the serious and
prolonged disturbances of individuals confronted with major life events.
Estimates of lifetime prevalence of PTSD among specific Western groups of trauma survivors
range between 15% and 24%,79 as compared to 8% in the general United States population.80
The prevalence of PTSD among refugee groups and other survivors of war or mass violence in
non-Western settings is similar to Western survivor ranges, though some are significantly higher.81

vi For a comprehensive overview see also Table 21.

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There has been a tendency in Western psychiatric research to focus exclusively on PTSD when
describing the mental health or even psychosocial consequences of violence. Understanding
human responses to extreme and catastrophic experiences solely in terms of PTSD has serious
shortcomings. First, not all disorders caused by traumatic events can be described in terms of
PTSD it is not the only possible disorder after traumatic events, even according to the DSM
system. Co-morbidity (most notably depression and generalised anxiety disorder) has been
found to be more prominent in trauma clients than has been originally assumed. Secondly, and
more importantly, it has been found that many people do not develop mental disorders at all.
Although nearly all people confronted with war will suffer various negative responses such as
nightmares, fears, startle reactions and despair, they will not all develop mental disorders. An
emphasis on PTSD overlooks the normal and healthy ways of adapting to extreme stress.82
Studies of various trauma populations show that individuals who spontaneously recover from
PTSD do so in the first three months. In Western settings, which are in general more favourable,
approximately 80% of people have been shown to recover without (para) professional support.83
For this reason, the DSM-IV defines PTSD as chronic if the duration of symptoms is three
months or more.
Tbl. 6

Criteria and Symptoms of Post-Traumatic Stress Disorder 84


Criteria

Observed as

The person is exposed to a


traumatic event in which:

Experienced, witnessed, or confronted event(s) involving actual


or threatened death or serious injury, or a threat to physical integrity
of others
Persons response involved intense fear, helplessness, or horror.

The traumatic event is persistently


re-experienced in at least one of
the following ways:

Unwanted images and/or thought


Dreams
Acting or feeling as if the events were recurring (e.g. reliving the
event, flashbacks)
Psychological distress at exposure to cues
Intense physiological distress at exposure to cues

The person persistently avoids


reactions to stimuli associated with
the event or numbing of general
responsiveness, and exhibits three
of the following:

Avoidance of thoughts, feelings, conversations of the trauma


Avoidance of activities, places, people that arouse recollections
Inability to recall important aspects of the trauma (amnesia)
Markedly diminished interest or participation in significant
activities (withdrawal)
Feeling of detachment from others
Restricted range of affect
Lack of future perspective

Hyperarousal, as indicated by at
least two of the following:

Duration of symptoms at least


more than one month

Acute: symptoms less then 3 months


Chronic: more than 3 months
Delayed onset: symptoms start at least 6 months after event

There is clinically significant


distress or impairment in social,
occupational or other important
areas of functioning.

Problems at work, difficulty adhering to rules and daily activities

Difficulty falling/staying asleep


Irritability or outburst of anger
Concentration problems
Hypervigilance
Startled responses.

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25

C.2.4 Other psychiatric co-morbidity


Survivors of traumatic events have been shown to be two to four times more likely to develop
other psychiatric disorders than clients with no history of trauma.85 Co-morbidity in the form of
depression, anxiety disorders, or chemical abuse/dependency, is found in 80% of survivors of
trauma and PTSD.86
C.2.5 Depression
A review of assessment studies shows elevated levels of depression ranging from 5%-31% in
refugee groups that suffer from psychological consequences of violence.87 Longitudinal research
shows that overtime baseline psychiatric disorders, most notably depression, among a refugee
population, remains 2 - 4 times higher than the general population in the same area.88
Suicide or suicidal ideas are common risk factors in depression. Among those suffering from the
psychological consequences of violence, self destructive impulsive behaviours,89 and high levels of
suicide attempts are recognised associated features.90 Less critical effects of depression are very
common, such as an inability to care for oneself or to engage with ones environment.
While the DSM provides a guideline for categorizing depressive symptoms, it is important to
understand how local definitions of self might affect a clients experience of depression,vii and
how emotions and symptoms are expressed. Causes and symptoms of depression differ
according to cultural context and behavioural norms.
Symptoms of depression are something difficult to distinguish from symptoms of anxiety.
Although a person may be primarily depressed, for example, s/he may also behave aggressively
and report feelings of tension and stress.The overlap between depression and anxiety is found
in both self-report ratings and clinical reports, in measures of mood such as subjective accounts
from clients, symptoms, syndromes and diagnoses.91
Tbl. 7 Overview of depression symptoms 92
Depression
A person is considered clinically depressed if s/he has suffered at least 1 of the following
for the past two weeks:
Depressed mood most of the day (self reported or observed by others)
Markedly diminished interest or pleasure in all or almost all activities during the day.
and if s/he has exhibited at least four of the following symptoms over the past two weeks:
Significant weight loss (this must be compared to others in the same situation)
Insomnia or hypersomnia
Psychomotor agitation or retardation observable by others (not only a subjective feeling of restlessness or slow down)
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Diminished inability to think or concentrate, or indecisiveness
Recurrent thoughts of death, recurrent suicidal ideas without a specific plan or suicide attempts

vii The transcultural psychiatry concept of self differs from the traditional Freudian one. It sees the self as culture-dependent, (i.e. not a static ego)
and is constantly evolving parallel to changes in its socio-cultural environment.

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C.2.6 Generalised Anxiety disorder


Anxiety disorder is a generalised term that refers to a group of psychological disorders
characterised by excessive tension and worry.93 In a generalised anxiety disorder the worry does
not focus uniquely on a fear of being in public (otherwise social phobia), of being contaminated
(obsessive-compulsive disorder), of being away from loved ones (separation anxiety disorder), or
of gaining weight (anorexia disorder), having multiple physical symptoms (somatisation disorder),
or having a serious illness (hypochondriasis); nor is the worry uniquely a form of panic
(otherwise panic disorder).The anxiety and worry do not occur exclusively during PTSD.94
Anxiety disorders may be linked to specific situations or involve general states, definable by the
DSM. Anxiety disorders or obsessive worrying are frequently described among survivors of
violence.95 In the first days to weeks after a traumatic event especially when displaced, anxiety is
part of the normal coping process.96 Therefore a generalised anxiety disorder can only be
diagnosed six months after the traumatic event. Symptoms of anxiety disorder can also be
caused by substance abuse or a general medical condition.
Tbl. 8

Overview of symptoms of generalised anxiety disorder 97


Generalised Anxiety disorder
A person can be identified as having anxiety disorder if s/he has been worrying for a period of six
months and exhibits at least three of the following symptoms:
Restlessness or feeling keyed up
Easily fatigued
Difficulty concentrating or mind goes blank
Irritability
Muscle tension
Sleep disturbance (difficulty staying, or falling asleep)
Clinically significant distress or impairment in social, occupational or other important areas of functioning

C.2.7 Chemical abuse/dependency


Alcohol and drugs are commonly used to soften emotional pain, and to forget or reduce anxiety.
Substance abuse among survivors of mass violence is often temporary. However for some it
becomes a long-term problem and addiction.98 Chemical abuse or dependency is proven to
have detrimental effects on all areas of health99 in both Western and non-Western cultures.
Tbl. 9

Overview of symptoms of substance abuse disorder 100


Substance abuse disorder
Prolonged substance abuse should lead to clinically significant impairment or distress. A person
can be identified as suffering substance abuse disorder if one or more of the following occurs within
a 12-month period:
Recurrent substance use resulting in a failure to fulfil major role obligations
Recurrent substance use in situations in which it is physically hazardous
Recurrent substance use related to (legal) problems (e.g. disorderly conduct)
Continuity substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated
by the effects of the substance

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27

C.3

Social, Spiritual and Moral Health

C.3.1 Relevance
The consequences of mass violence on social, moral and spiritual health are less obvious
than effects on physical and mental health, but the damage caused is equally devastating.
Mass violence affects individual and group coping processes. It hampers peoples ability to
redefine (individual and group) core values and social attitudes.
Evidently, social, spiritual and moral health consequences are strongly influenced by culture.
Research about the effects of mass violence on social, spiritual and moral health is growing,
but remains scarce compared to that done on physical and mental health.
C.3.2 Social health
Experiences of mass violence have a detrimental effect, first and foremost, on intimate
relationships. Problems in marriage, family life and sexual functioning, poor social support
networks or withdrawal from society are common reactions to mass violence across
cultures. Survivors often experience unstable and unsuccessful work lives such as frequent
career and job changes, low paid work or very successful ones at the expense of family or
interpersonal relationships.101
The social health of the individual directly influences the social functioning of the group. Mass
violence affects the social fabric and social capital of a community.102 Key people like traditional
and religious leaders and village elderly in the community may lose their status. A communitys
set of (un)written rules on rights and obligations (social order) may erode. Its ability to care for
its vulnerable people itself through, for instance, community self-support may be affected. Social
cohesion of the group might be diminished, as everybody is pre-occupied with their own
traumatic experience. Disharmony may increase, resulting in increased aggression or schisms.
Mechanisms that create and confirm community cohesion such as story telling, folk dancing
may disappear.
C.3.3 Spiritual health
Human beings use spirituality to give meaning to the unimaginable, the unpredictable and the
unexplainable. Spirituality, often expressed through religion, ideals or philosophical ideas is a
strong resource for fostering acceptance and integration of traumatic experiences.
In the aftermath of the traumatic experience spirituality can become a major stressor or source
of inspiration. Experience shows that survivors of mass violence can either become more
religious, expressed through increased prayer for instance, or lose faith resulting in spiritual crisis
or beliefs of being cursed.The loss of belief in the benevolence of people, authorities, religion or
a meaningful future may result in cynicism.
Rituals are symbolic ways of giving spiritual meaning to an event, coming to terms with or
controlling the unmanageable. Mass violence can reduce an individual or groups capacity to
perform rituals, due for instance to a lack of people to execute the rituals.

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

C.3.4 Moral health


Experiences of mass violence can have serious effects on individual and group moral values.
They can affect peoples moral judgments, and cause feelings of survivor guilt, shame and
outrage, and shatter moral beliefs about trust and the benevolence of people.
Anger and frustration about what is lost and what has happened is often high among
survivors.Thinking about and acting out of revenge can be a sign of affected moral health in
certain cultures.
Old community rules may not necessarily be regarded as functional for survival or
reconstruction. Lack of respect for marriage rules, sexual behaviour etc. may result in negative
changes in moral (and physical) health. Though phenomena such as substance abuse and
prostitution are primarily regarded by Westerners as physical and social health problems,
in most non-Western cultures these are also regarded as a sign of affected moral health.
Societal, community and individual moral values directly influence mental health legislation.
Culture-bound notions about what is normal or abnormal behaviour are translated into
legislation as being good or bad, legal or illegal.103 If a mental disorder is defined by a
community/society as abnormal and bad, it may be criminalized. Conversely criminal behaviour
might be medicalised and justified by ascribing or by giving it a diagnostic label. Survivors of
traumatic events can find themselves in a dangerous situation where the legal system punishes
them for their medical status.
Table 10: Overview of symptoms of social, spiritual and moral health problems
Social Health
Individual

Marriage problems/ child abuse


Sexual functioning
Withdrawal from society
Over pre-occupation with work
Substance abuse

Poor family life


Poor social support networks
Unstable work lives
Apathy

Loss of community cohesion

Across cultures some common (general) indicators of this loss are:


Loss of caring capacity: mechanisms that are used to protect vulnerable groups
Social disintegration: the normal social order (e.g. written or (un)written rules on
responsibilities) in the community disappears.
Decrease of social capital in a society (e.g. lack of trust)
Loss of status of traditional leaders and significant people (e.g. chiefs, elderly) in the
community
Loss of normal income generating activities
Community conflict/schisms
Community disharmony
Increased sexual violence
Disruption of customary or traditional activities
Increase in drugs and alcohol abuse

Spiritual Health

Decreased or increased religious belief


Cynicism

Moral Health

Beliefs in being cursed


Loss of rituals

Survivor guilt
Shame
Outrage, anger and frustration
Revenge
Prostitution
Changed marriage rules
Shattered values and principles of basic (unwritten) community rules

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

29

C.4

Children

C.4.1 Psychosocial services for children


Childrens reactions differ from adults because they are in the process of developing emotional,
cognitive, behavioural and sensory skills. Childrens reactions to mass violence depend on their
developmental stage and age.
Children who are exposed to single traumatic experiences often recuperate, and do not
develop any psychopathology. If traumatic reactions continue for a prolonged period of time, or
if a psychopathology prevails, a child can become fixed in his developmental stage.The child feels
too unsafe to experiment with new situations.
C.4.2 General reactions
Children often exhibit several generalised reactions after they experience a traumatic event:
Re-experiencing (intrusion):The re-experiencing of a traumatic event, through intrusive
memories, dreams/nightmares, etc., can happen at all ages, and commonly occurs in quiet
moments when the child is alone.Younger children only re-experience parts of the memory
while older ones have full flashbacks. Intrusions often lead children to experience general
anxiety.
Anxiety: Children can become afraid to go to bed and subsequently become (extremely)
tired.This physical anxiety and fatigue in turn causes concentration problems, irritability and
bouts of anger.
Post-traumatic play: The capacity for verbal expression is limited in children.They use play in
various forms and drawing to express what they have experienced.This post-traumatic play is
often repeated endlessly. After a long time the theme of the drawing or play changes from
helplessness to control. As a result the child becomes less anxious.
Avoidance: After a traumatic experience children tend to limit their emotions.They may not
express emotions while telling about their experiences. As a result they create the impression
that they are doing well. If not given sufficient attention they feel detached, lonely and not
understood. Some children slowly withdraw. Avoidance may also present itself as reluctance to
speak and as destructive behaviour.
C.4.3 Infants and toddlers
The age of infancy and what is expected from children varies among cultures. However, there is
a general and universal understanding that the major task of this age group is to develop basic
skills and trust in themselves and others.They increase control over their body and impulses.
They develop autonomy and understanding of the world around them.
Infants and toddlers perception of what constitutes an external threat is generally determined
by the reaction of their parents. Infants and toddlers are highly dependent on the coping skills of
their parents.The fear of being separated from the parent is shown through clamping behaviour.
The death of a parent is a form of extreme separation: the child might continue to search for
his parent. If the missing parent appears in dreams the children becomes very confused.

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Children in this age group often remember one aspect of the event (not necessarily the most
important), and often endlessly repeat themes from their traumatic experience in their play or
drawing.Traumatised children often play alone.
Regressive behaviour like bedwetting or thumb sucking can occur. Social behaviour becomes
either withdrawn and silent or aggressive and demanding. Sleepwalking, talking in the sleep,
nightmares and general restlessness is often picked up by the parents as sign of alarm.These
reactions disappear over time in most cases.
C.4.4 School children
Children in the age group of approximately 6-12 years old have gained independence.They
understand better what is going on and depend less on the reactions of their parents.
The stage of development permits them to react in cognitive, emotional and behavioural ways.
Achievements in school are useful indicators for determining how well or poorly a child is
processing a traumatic experience. Achievement levels may drop and concentration difficulties may
be reported. Traumatised children may engage their school friends in their post-traumatic play.
The child deals with his powerlessness, rage or feelings of guilt by having saviour or revenge
fantasies. Since the child has developed at this stage a sense of right and wrong (conscience),
s/he may feel very guilty for not having reacted differently during the traumatic experience, and
for having revenge fantasies.
Children in this age group have a tendency to worry about their parents, and are reluctant to
bother their parents with their own fears.
C.4.5 Adolescents
Adolescence is characterized by major biological, psychological and social changes. Definitions of
adolescence vary among cultures in terms of age, roles and responsibilities.The development of
social autonomy is very important during adolescence. Friends and peers become more
important than parents. Fear of rejection, problems in developing independence, and
ambivalence towards parents are part of the uncertainties almost every adolescent is
confronted with.
A traumatic experience can seriously hinder the process of detachment. Extreme fear may
increase the sense of dependency on parents.This regression may be difficult for an adolescent
to accept. The associated loss of control and sign of weakness causes the adolescent to feel
humiliated before friends.
Adolescents generally exhibit extremely strong emotions, and are critical about themselves.
While evaluating their past traumatic experience(s), they may strongly denounce themselves or
feel guilty. Sometimes these emotions are suppressed and acted out through conflict or
aggressive behaviour. Conflicts with parents may increase and substance abuse may start.
As with children, adolescents have an instinctive urge to re-live their traumatic experience
through re-enactment behaviour such as post-traumatic play. In their re-enactment they may
take the role of a victim. However, to increase control and manage their feelings of shame they
may take on the role of the aggressor. Both may result in extremely dangerous situations as
adolescents are physically mature and often have easy access to weapons.

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31

C.4.6 Reactions within the family


Traumatic reactions within a family are often contagious.The traumatic experience of one family
member can often be shocking for all. Parents may react by being overprotective of the child.
The child may become anxious if it is separated from its parents. If parents and children have
been exposed to the same event, children may become very worried about their parents.They
become less naughty.
Tbl. 11 Overview of expressions of children exposed to traumatic experiences
Age group

Expressions

General

Re-experiencing
Sleeping problems
General anxiety, irritability
Fatigue
Concentration problems

Infants,Toddlers

Highly depending on coping skills of parents


Clamping behaviour
Post-traumatic play: alone
Regressive behaviour (bedwetting, thumb sucking)
Silent/withdrawn or aggressive/demanding

(Developmental tasks: basic trust, increase control


over their body and impulses, develop autonomy
and understanding)
School children
(Developmental tasks: gaining independence and
understanding, depending less on reactions of
their parents, maturing cognitive, emotional and
behavioural ways of expression)
Adolescents
(Developmental tasks: detachment, autonomy,
friends or peers more important then parents,
improved cognitive skills, emotional, social skills,
increase control)

Signs of alarm

32

Post-traumatic play
Contain their emotions
Detachment
Loneliness
Obstructive behaviour

Achievements may fall back


Concentration difficulties
Post-traumatic play: school friends
Saviour or revenge phantasies
Strong guilt feelings
Worry about parents (acting/caring as parents)

Increased sense of dependence


Feelings of shame
Extreme conflicts with parents
Feeling acted out through aggression, conflicts
Increased substance abuse
Strong self denouncement or guilt
Post-traumatic play: as victim or perpetrator

Signs, complaints increase over time


Increase of concentration problems
Mental confusion
Increase of withdrawal behaviour
Excessive fatigue

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

TOWARDS A GENERAL FRAMEWORK & POLICY

D.1

Scope of the intervention

D.1.1 Individual care and community support


The interdependency between the individual and his environment is an important element
of the coping process. Programmes that address the psychological consequences of violence
have to pay attention to this specific relationship. In psychosocial projects a joint approach
of both individual care and community support is vital.The psycho and socio elements
should be complementary in order to ensure that individual and environmental healing
capacities are mobilised.104
D.1.2 Focus of intervention
Psychological health rests on a continuum of psychological well-being. Partly depending on the
cultural ideas of a community, an individuals psychological state can be defined as normal and
healthy, or as abnormal and mentally ill. Between these two extremes is a large middle category
of psychosocial problems, see Figure 5.
The answer to the question: What focus is appropriate for mental health or psychosocial
intervention? often depends on the type of emergency situation at hand. Firstly, all medical
interventions need to have psychological and social components. However, in acute emergencies
health projects focus on those mental disorders that cause immediate danger to physical
survival. Meanwhile, in chronic crises, they generally focus less on mental disorders and more
on psychosocial problems that hamper peoples coping process.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

33

Fig. 5

Mental health continuum (Arrows indicate changes caused by mass violence)

M
E
N
T
A
L
E

Psychiatric &
psychological disorders

DISORDER

A
L
T
H
O

Psychological &
psychosocial problems

AT RISK

N
T
I
N
U
U

No problem

T O T A L

P O P U L A T I O N

D.1.3 Early intervention


The process of coping and adaptation starts at the onset of an emergency.Therefore, mental
health disorders and psychosocial problems need to be addressed from the beginning of an
emergency. Research increasingly confirms the importance of early intervention.105

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

D.2

Objectives

D.2.1 General objectives of mental health projects


Mental health projects are aimed at reducing suffering caused by mental disorders. Especially in
the first stage of an emergency, drug therapy and (secondary) psychosocial support are
combined.
D.2.2 General objectives of psychosocial projects
The overall objective of psychosocial projects is to reduce the psychological consequences of
mass violence.To achieve this, two elements are distinguished.The psycho-component provides
support on the individual level. It facilitates the reconnection of the affected individual to his
environment, his community, and his culture.The socio-element aims to create an environment
that facilitates the individual or rather groups of affected individuals; to re-integrate.
Both elements need to be addressed in any psychosocial project.The importance of and the
balance between both elements (the psychoand socio) in a project depends on cultural,
environmental circumstances, phase of emergency, etc.106
For a detailed description of objectives see the chapter on Project Planning J.
D.3

Package of Psychosocial Activities

D.3.1 Psychological package


The psychological element of the project is delivered as a package, see Figure 6.107
All components of this psycho logical package must be in place, either in the form of direct
services or of a referral, to ensure a comprehensive programme.The psycho logical package
includes the following components:
Psychiatric support: In acute emergencies (temporary) psychiatric support is given within the
project by expatriate and national specialists.To avoid dependency on external specialists in
chronic crises, psychiatric support is usually provided through referral of the clients to existing
medical or psychiatric services.
Supportive Counselling: Counselling is offered as emotional support to individuals and small
groups.The counselling does not aim primarily to heal or to cure people of their psychosocial
problems. In situations of acute or ongoing humanitarian crisis and exposure to traumatic
events, healing or curing is not realistic.The role of the counsellor is to support and improve
the coping mechanisms of beneficiaries. Supportive counselling provides people with some
emotional support, and practical advice. It helps people to increase their self-control through
education, social skill improvement and to boost their resilience through mobilisation of selfsupport factors (physical, mental or social).The counselling interventions are based on
cognitive behaviour techniques and brief therapy principles that are translated to the existing
cultural environment.

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35

The process of coping with traumatic experiences includes the capacity to give meaning to the
experience. In many non-Western societies meaning is given through the spiritual world.
Spirituality is an important coping mechanism.The areas of moral and spiritual health are difficult
for Western NGOs and psychosocial counselors to address. Psychosocial projects can include
spiritual leaders as advisors or as referral options. Rituals and ceremonies can be stimulated.
Nevertheless, it should be born in mind that humanitarian aid workers are also bound by their
own ethical principles and quality standards.
Training: Training of national staff is necessary to increase or to introduce skills and
knowledge.Therefore, national health staff are trained to identify psychological and psychiatric
problems.They are trained on, for instance, communication skills to offer basic support to their
clients in their work settings. National counsellors are trained in two issues: to give more
intense individual support to survivors of violence and to work in the community, see D.3.2.
Socio package. A specific training method has been developed for the training of national
counsellors,108 see Chapter K Training.
Advocacy: Proximity to beneficiaries is essential for showing empathy, solidarity and
compassion.The changing environment requires ongoing monitoring of needs. Human rights
violations necessitate speaking out or advocating for those who cannot speak.
D.3.2 Social package
The social component of a project addresses psychosocial problems on a group level. A package
of activities is proposed to stimulate the re-integration of traumatised people and to facilitate
the coping of large groups of people. All components of the social package should be delivered,
otherwise resilience or protective factors can only be partly mobilised.The social package
includes the following components:
Practical support: Traumatised people and populations need a lot of practical, physical support
to enhance their recovery environment. Medical services, water and sanitation assistance or food
support are just some examples.The prevalence of needs is often overwhelming.Therefore,
to ensure appropriate referrals of those in need for practical support, expatriates, national
counsellors and community workers need to know what is available in the community (social
map).To provide adequate support and to foster self-help mechanisms the national staff s
understanding of social and culturally appropriate methods is vital. Since not all support can
be expected from the community, close cooperation among NGOs needs to be stimulated.
Community education: Large-scale education about prevailing psychosocial problems in the
community is necessary to increase self-control and self-help. Education also assists to diminish
taboos about mental health and psychosocial problems. Furthermore, it increases awareness
about counselling services.
Community mobilisation: The social fabric of communities is often affected by mass violence.
This results in a reduction of peoples protective mechanisms. After mass violence the
regeneration and revitalisation of new or former community structures often requires
facilitation from outside. Cultural leaders such as chiefs, religious leaders, the elderly must
be stimulated to re-assume their roles. Grass root initiatives need assistance and stimulation.
They often prove to be important mechanisms for the provision of practical support.
Local cultural groups like theatre, or folk play companies are often instrumental in creating
a better atmosphere.

36

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

Community Activities: The atmosphere in refugee and internally displaced camps is often far
from uplifting. Community activities can be used to improve the general atmosphere, to
stimulate community action on general issues like hygiene promotion, or to re-start
community cultural customs like dancing or story telling.These activities intend to improve the
sense of belonging. Extensive networking with both significant people in the community and
(folk) artists are required to achieve this.
Advocacy: Human rights are universal and must be respected. Counsellors and expatriates
have the right to speak out (advocacy) against human rights abuses and to raise awareness
about issues like sexual violence.
For a detailed description of activities see the chapter on Project Planning, Chapter J.
D.3.3 Integration and comprehensive medical services
The nature of mental health and psychosocial care requires a multi-disciplinary approach.
The evident relationship between traumatic exposure and poor health suggests intensifying the
collaboration between primary and specialty medical care.109 Collaboration is mandatory to
improve early identification and treatment.
To emphasize the collaboration mental health interventions are managed as integrated elements
of health interventions for instance through joint project planning as much as possible.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

37

Fig. 6

Intervention model for psychosocial projects to address the psychological consequences of violence
through individual and community interventions.

Vulnerability

Resilience
Physical, Mental, Social,
Spiritual, Moral part

Event related,
Personal,
Recovery environment

Traumatic
event(s)

Avoidance

Integration

Intrusion

Not coped

Coping process

Physical, mental, social, spiritual,


moral problems

38

SOCIAL PACKAGE

PSYCHOLOGICAL PACKAGE

Practical support
Community education
Community moblisation
Key people
Grass root organisations
Community activities
Distraction
Networking
Advocacy

Advocacy
Psychiatric support
Counselling support
Education
Emotional support
(Social) skill training
Advice
Training other health staff

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

PART I1
PROGRAMMING DETAILS

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

39

INDIVIDUAL TREATMENT AND SUPPORT


Individual treatment for mental health and psychosocial problems varies.The treatment
approach depends, for instance, on type and severity of the complaint, expectancy of beneficiary,
cultural attitudes, time available for client, and previous treatment. Also, operational constraints
such as security conditions, accessibility, stage of the conflict, other health needs or resources
available influence the choice of treatment.
Some methods like drug therapy target symptom reduction as the major clinical outcome
by which efficacy is judged. Other treatments first address the severe disruptive behaviours.
Clients suffering from less acute problems or disorders often receive treatment such as
psychosocial support, and cognitive-behavioural oriented brief-therapyviii that emphasize
improvement in daily functioning.The underlying problem or pathology is managed instead of
cured because it is the clients priority or the condition causing the problems is unlikely to
change quickly, for instance an ongoing war.These approaches are all relevant for psychosocial
programmes addressing the consequences of mass violence.
Finally, some treatments such as psychotherapy seek to enrich the therapeutic process through
promoting insight in intra psychic processes.The latter objective is less relevant for acute
emergencies or chronic crisis and therefore hardly ever used in MSF programmes.

E.1

Acute Crisis Intervention


A client may suffer from: acute psychiatric problems like anxiety disorder, panic disorder, suicide,
psychosis, acute stress disorder, or acute PTSD, agitation, or severely disruptive behaviour such as
aggression, absent mindedness, ongoing flashbacks, withdrawal, shock.The aim of treatment is to
provide protection of the client or his environment, to immediately reduce symptoms, and to
restore control either by the client him/herself or by the informed support network. A strong
and directive attitude in treatment is appropriate.Three interventions should be applied and
often combined: cognitive-behavioural techniques, drug therapy and social or practical support.
Cognitive behavioural techniques include: stimuli reduction, containment of emotions,
normalisation of certain reactions, helping clients to challenge irrational thoughts, restoration
of the here and now, listening, structuring of thoughts or emotions, and restoration of control
through, for instance, behaviour prescription, advice and education.The priority is to contain
the problem.Therapeutic techniques that are not useful in acute crisis include emotion
exploration techniques or exposure therapy. Personal or moral judgments, inappropriate
reassurance like at least you survived or denying of guilt are inappropriate for caregivers.
Drug therapy: see section E.2
Social and practical support for the individual requires consideration. Severely affected people
require close observation and a family or other social support network should therefore be
mobilised. Also, the provision of practical support for instance a quiet shelter for both
caregivers and clients needs attention to complete case management.

viii See section O for definition.

40

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

Tbl. 12 Overview of acute crisis intervention strategies in MSF psychosocial, mental health projects
Crisis intervention

Support/Treatment

Avoid

(Aim: to provide protection of the client or


environment, to immediately reduce symptoms,
and to restore control (either by the client
him/herself or the informed support network).
Psychiatric problems

Cognitive behavioural techniques

Anxiety disorder
Panic disorder
Suicide
Psychosis
Acute stress disorder
(or acute PTSD)
Agitation

Severely disrupted behaviour


Aggression,
Ongoing flashbacks
Shock

Stimuli reduction
Containment of emotions
Normalisation of reaction
Helping clients challenge irrational thoughts
Challenging negative thinking
Restoration of the here and now
Listening
Structuring of thoughts (and emotions)
Restoration of control (e.g. behaviour
prescription, advice, education)
Relaxation
Restoration of daily routines

Emotion exploration techniques


Judgments (personal, moral)
Inappropriate reassurance
(e.g. at least you survived)
Denying of guilt

Social
Provision of practical support
Exploration/mobilisation of support network
Drug therapy
See section E.2

E.2

Severe psychiatric or psychological mental health conditions: Drug therapyix

E.2.1 Consider before prescribing


E.2.1.1 Organic causes
The first step in assisting clients with severe psychiatric or psychological conditions is to exclude
underlying organic causes. For instance neurological disorders may present themselves as
psychosis; hyperthyroidism as anxiety and hypoglycaemia as irritability. Conversely, certain
physical symptoms can be associated with psychological or psychiatric conditions. For example,
hyperventilation, dyspnoea and heart palpitations are common in panic-attacks. Anorexia and
vague pains may indicate depression, while delusions caused by organ dysfunction might be
interpreted as psychosis.
E.2.1.2 Substance abuse
Consider substance related disorders like intoxication by alcohol, solvents, opiates, cannabis etc.
or the opposite, namely withdrawal from these substances. Both can result in psychiatric-like
symptoms such as depression, anxiety, hallucinations. Substance abuse might also be concurrent
with a mental health disorder. In this case the origin of the symptoms should be established only
after the substance use is stopped.

ix In this paragraph most of the material has been taken from: (2003). Clinical Guidelines: diagnostic and treatment manual for curative programmes in
hospitals and dispensaries. Guidance for prescribing. France: Mdecins Sans Frontires.

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41

E.2.1.3 Cultural expression


Lastly, some symptoms are culturally shaped.They are not the manifestation of a disorder but a
normal cultural mode of expression. For example, receiving signs from and speaking with
ancestors may be culturally normal in certain circumstances like the mourning process, and not
a sign of a delusion disorder.To increase understanding about local modes of expression, it is
advisable to work with anthropological informants.
E.2.2 Place and use of drug therapy
Drug therapy is only one aspect of treatment for psychiatric clients. Always consider first the use
(or the combined use) of cognitive behaviour crisis intervention, counselling, psychotherapy, and
addressing social factors.
The prescription of psychotropic drugs is only appropriate when it is medically necessary.
Certain psychotropic drugs may lead to dependence (caused by increased tolerance), or
establish an avoidance cycle such as Benzodiazepines and severe withdrawal symptoms on
cessation. Iatrogenic addiction must be considered.Therefore rationalise the use of:
Phenobarbital:This drug is often inappropriately used as sedative. It should only be used
for epilepsy!!
Benzodiazepines (diazepam, valium): should only be prescribed for clear medical reasons for a
maximum of 2-3 weeks.
Other considerations should include:
Age: no psychotropic drugs below 15 years.
Pregnancy and breastfeeding: only when absolutely necessary and the lowest effective dose.
Tbl. 13 Considerations for prescribing psychotropic drugs
Examine underlying problems (physical, mental, substance-related)
Always consider first or combine cognitive behaviour crisis intervention, counseling or psychotherapy
Use informants to identify cultural modes of expressions
Only medical doctors should prescribe drugs
Risk of iatrogenic addiction or intense withdrawal syndrome
No prescription of drugs for children under 15 years
Pregnancy, breastfeeding: drugs only when absolutely necessary & at the lowest effective dose
Monitor for contra-indications

E.2.3 Supportive counselling


See section E.3
E.2.4 Drug prescription
The drugs mentioned below are on the essential drugs list, and are effective, affordable and
available in most countries in the world.The drugs should be stored appropriately and locked.
Only medically trained and certified doctors should be allowed to prescribe drugs.

42

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

E.2.5 Anxiety disorder


The symptoms present are psychological such as unexplained fear, fear of dying or going crazy
etc. and physical symptoms like palpitations, difficulty in breathing, feeling of general malaise, and
hyperventilation. Anxiety may be acute, an overwhelming psychological malfunctioning or a
persistent, chronic state.
E.2.5.1 Isolated anxiety cases
Always try to first normalise the client; explain the reaction or encourage controlled breathing.
Use one-on-one counselling, involving listening in an understanding and reassuring manner. If this
fails to resolve an acute anxiety or panic attack, treat with diazepam: 5 to 10 mg PO or 10 mg
IM, to be repeated after 1 hour if necessary.
Reactionary anxiety, if incapacitating, may sometimes justify a short-term treatment with
diazepam PO: 5 to 15 mg/day in 2 or 3 divided doses for a few days.
E.2.5.2 Underlying mental disorders
Anxiety is a constant feature of depression. In addition to antidepressant treatment, give
diazepam PO: 5 to 15 mg/day in 2 or 3 divided doses for the first 2 weeks of treatment.
Anxiety during psychosis can be relieved with chlorpromazine PO: 25 to 150 mg in 2 or 3
divided doses. During a crisis prescribe, chlorpromazine IM: 25 to 50 mg
Anxiety is a characteristic feature of traumatic stress disorders that requires specific treatment,
see section E.2.7 for details on PTSD.
E.2.5.3 Contra-indication
Diazepam is strictly contra-indicated in clients with respiratory impairment.
E.2.6 Depression
Depression is characterized by a set of symptoms that vary, but occur over a period of at least
2 weeks. Symptoms include: sadness, thoughts of death, loss of interest and pleasure, fatigue,
slowing or agitation, sleep disturbances, loss of appetite, feelings of worthlessness or guilt, poor
concentration, anxiety.
Symptoms of depression are common following a death or a significant loss; initial treatment
should not be with antidepressants. In these cases start with supportive care (see crisis
intervention or supportive counselling E.3), and treatment with anxiolytics.
Antidepressants should only be prescribed if the client can continue treatment for at least 6
months after the improvement of symptoms and if regular follow-up in the form of psychosocial
support, monitoring of compliance and clinical evolution is possible:
Either clomipramine PO: initial dose of 25 mg once daily, to be progressively increased (over
several days) to 100 to 150 mg once daily.
Or, if available, fluoxetine PO (which does not have the same adverse cardiac effects): 20 mg
once daily.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

43

These dosages must be maintained for 6 months after symptom improvement. Be aware that
the adverse effects of clomipramine and fluoxetine appear in the first days of treatment while
the therapeutic effects are not seen for 3 to 4 weeks.This must be clearly explained to the
client.
Suicide risk is increased from the 10th to 15th days of treatment. Diazepam may be added to
the treatment, particularly in clients with severe depression, severe anxiety or incapacitating
insomnia: diazepam PO: 5 to 15 mg/day in 2 or 3 divided doses, for a maximum of 2 weeks.
E.2.6.1 Contra-indication
Clomipramine is contra-indicated in clients with cardiac arrhythmia or with a recent history of
myocardial infarction.
E.2.7 Post-traumatic stress disorder (PTSD)
At least 20% of individuals who have been exposed to traumatic events develop long-term
psychological and psychosocial problems.These problems, such as unexplained somatic
complaints, phobias, anxiety, relationship problems, depression and behaviour disorders are often
expressed indirectly, for instance, through repeated consultations in health clinics.
The short-term treatment of PTSD with benzodiazepines should only be done with great
caution.They are not very effective, may even cause future problems because clients do not
learn how to cope with or overcome their problems by themselves, and rapidly become
dependent (see paragraph E.2.2 Place of and use of drug therapy). Benzodiazepines may be
useful for a short period of time in clients with insomnia.
Clomipramine is effective against anxiety and increased arousal, and may reduce flashbacks. If
cognitive-behavioural techniques or supportive counselling fails and symptoms persist or if
depression complicates the clinical picture, administer:
Either clomipramine PO: initial dose of 25 mg once daily, to be progressively increased (over
several days) to 100 to 150 mg once daily.
Or, if available, fluoxetine PO (which does not have the same adverse cardiac effects): 20 mg
once daily.
These dosages must be maintained for 6 months. Be aware that the adverse effects of
clomipramine and fluoxetine appear in the first days of treatment while the therapeutic effects
are not seen for 3 to 4 weeks.This must be clearly explained to the client.
E.2.7.1 Contra-indication
Clomipramine is contra-indicated in clients with cardiac arrhythmia or with a recent history of
myocardial infarction.
Suicide risk is increased from the 10th to 15th days of treatment. Diazepam may be added
to the treatment, particularly in clients with severe depression. In cases of severe anxiety
or incapacitating insomnia: diazepam PO: 5 to 15 mg/day in 2 or 3 divided doses, for a
maximum of 2 weeks.

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E.2.8 Psychosis
Psychosis is an acute or chronic pathological state characterized by the presence of delusional
thoughts: the client is convinced of things that are beyond reality such as hallucinations, ideas of
persecution etc.The delusions are sometimes associated with ego splitting like in schizophrenia
or brief psychotic disorders in which there is a loss of coherence between the effect, thoughts
and behaviour and a lack of continuity in thoughts and speech.
Symptoms are improved with the use of haloperidol PO (3 to 10 mg/day) that must be
prescribed for an extended period of time. If extra-pyramidal adverse effects occur, it may be
helpful to add biperiden PO (2 mg 1 to 3 times/day).Treatment must include psychotherapy
and social therapy and, whenever available, care by mental health specialists (particularly if there
is a risk of confusion with culturally shaped manifestations).
E.2.9 Agitation
Psychomotor agitation requires a diagnostic process that is rarely immediately possible.
Do not forget medical causes like neurological disorders, infections, sepsis and toxic causes such
as intoxication, or withdrawal.
Moderate agitation without respiratory difficulty:
Diazepam PO or IM: 10 mg to be repeated after 30 to 60 minutes if necessary.
Significant agitation and/or signs of psychosis (loss of contact with reality, delirium):
Chlorpromazine PO or IM: 25 to 50 mg to be repeated a maximum of 3 times in 24 hours
E.2.10 Insomnia
There are several causes for, and types of, insomnia:
Insomnia linked to life conditions (life on the streets, in institutions etc.): there is no specific
treatment.
Insomnia linked to a physical problem: do not give sedatives, treat the cause (e.g. give
analgesics for pain).
Insomnia linked to drug therapy (corticosteroids) or use of toxic substances (alcohol etc.):
treatment is adapted on an individual basis.
Insomnia linked to a mental disorder (depression, anxiety, PTSD, delusional state):
symptomatic treatment for no more than 2 weeks may be given (diazepam PO: 5 to 10 mg
once daily at night).The underlying cause must be treated.
Isolated insomnia, usually linked to a particular event: symptomatic treatment with diazepam
PO: 5 to 10 mg once daily at night for no more than 2 weeks.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

45

Tbl. 14 Summary of drugs and prescriptions in MSF psychosocial, mental health projects.
ALWAYS read accompanying text above
Drug therapy & prescription details
Anxiety

1. Anxiety may be isolated:


Acute anxiety (panic attack): If normalising the symptoms, explaining the reaction or controlled
breathing fails, treat with diazepam: 5 to 10 mg PO or 10 mg IM, to be repeated after 1 hour
if necessary
Reactionary anxiety (if incapacitating): short-term treatment with diazepam PO: 5 to 15 mg/day
in 2 or 3 divided doses for a few days
2. Always look for an underlying mental disorder:
As constant feature of depression: antidepressant treatment, and diazepam PO: 5 to 15 mg/day
in 2 or 3 divided doses for the first 2 weeks of treatment
During psychosis: chlorpromazine PO: 25 to 150 mg in 2 or 3 divided doses or during crisis,
chlorpromazine IM: 25 to 50 mg
As feature of traumatic stress disorders that requires specific treatment (See below, post-traumatic
stress disorder).
Contra-indication
Diazepam is strictly contra-indicated in clients with respiratory impairment.

Depression

Either clomipramine PO: initial dose of 25 mg once daily, to be progressively increased (over several
days) to 100 to 150 mg once daily
or, if available, fluoxetine PO (which does not have the same adverse cardiac effects): 20 mg once
daily
Contra-indication
Clomipramine is contra-indicated in clients with cardiac arrhythmia or with a recent history of
myocardial infarction.

PTSD

Either clomipramine PO: initial dose of 25 mg once daily, to be progressively increased (over several
days) to 100 to 150 mg once daily
or, if available, fluoxetine PO (which does not have the same adverse cardiac effects): 20 mg once
daily
Contra-indication
Clomipramine is contra-indicated in clients with cardiac arrhythmia or with a recent history of
myocardial infarction.

Psychosis

Haloperidol PO (3 to 10 mg/day), prescribed for an extended period of time.


If extra-pyramidal adverse effects occur, it may be helpful to add biperiden PO (2 mg 1 to 3
times/day)

Agitation

1. Moderate agitation without respiratory difficulty:


Diazepam PO or IM: 10 mg to be repeated after 30 to 60 minutes if necessary.
2. Significant agitation and/or signs of psychosis (loss of contact with reality, delirium):
chlorpromazine PO or IM: 25 to 50 mg to be repeated a maximum of 3 times in 24 hours

Insomnia

Insomnia linked to drug therapy (corticosteroids) or use of toxic substances (alcohol etc.):
treatment is adapted on an individual basis.
Insomnia linked to a mental disorder (depression, anxiety, post-traumatic stress disorder, delusional
state): symptomatic treatment for no more than 2 weeks may be given (diazepam PO: 5 to 10 mg
once daily at night).The underlying cause must be treated.
Isolated insomnia, usually linked to a particular event: symptomatic treatment with diazepam
PO: 5 to 10 mg once daily at night for no more than 2 weeks.

Cognitive behavioural techniques & supportive counselling


Supportive counselling or psychotherapy increase outcome of drug therapy in many disorders.

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E.3

Supportive counselling

E.3.1 Psychosocial support in the medical setting


Psychosocial problems can be detected and addressed easily in medical settings. However, this
does not mean that the majority of mental health or psychosocial problems present themselves
in the medical setting. Depending on an individuals age (e.g. children), local culture and stigma
surrounding mental health illnesses, people with psychosocial problems can present themselves
elsewhere for instance at schools, community centers or to traditional healers.Therefore,
outreach and community presence is a vital component of psychosocial interventions.
Most people suffering from consequences of violence are able to help themselves. Psychosocial
support in the medical setting aims to recognise and normalise psychosocial reactions, to allow
expression of emotions in a safe environment, and to reinforce existing, or introduce new
coping behaviour.
Medical staff such as doctors and paramedical staff should already have been trained in basic
communication skills and techniques to provide emotional support. However, it may be
necessary to supplement this with specific training on topics such as traumatic stress, sexual
violence or HIV/AIDS etc, which can be done in the field.
Psychosocial interventions include: active listening, controlled expression, problem structuring,
provision of education or information and non-directive advice, enhancement of self-control,
restoration of daily routines and stimulation of social activities.
E.3.2 Individual & group counselling
Most non-Western countries have a lack of mental health professionals. Counsellors must be
trained and only allowed to work under supervision of a senior mental health professional.
The role of counsellors should not be mistaken for that of psychologists.The aim of supportive
counselling is to enhance the clients functioning by reinforcing his coping skills. Healing or
curing is not the main focus because in emergency contexts the risk of new traumatic
experiences is substantial.
Counsellors should use a simplified diagnostic system to categorise problems presented by a
client into five areas:110
Practical problems
Lack of skills
Complaints and behaviours related to traumatic experiences or extreme stress
Overwhelming feelings
Inner problems

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47

These categories are used to give direction to a counselling intervention.They are not used for
differential diagnostic purposes. Clients often express combinations of problems such as practical
problems and overwhelming feelings. It is part of the counsellors job to define, together with
the client, the most prominent complaint or area of dysfunction to be treated first. Once a
persons reaction to therapy has been evaluated, counselling support can be modified.
Lengthy intake procedures should be avoided. Counsellors should provide the necessary
support and encouragement for the client to make his own decisions. If more sessions are
required, then either the complexity of the problem is too high, the support not adequate or
transference and counter-transference are too intense. However, for most cases two or three
sessions are sufficient. If the clients problems re-occur or others develop over time the client
can return.
The counselling approach and interventions during the session are based on the principles of
cognitive behaviour brief therapy.The focus of cognitive behaviour therapy is to improve the
coping skills, to facilitate self-control and to enhance the resilience of clients. Dolls 111 can be used
to clarify situations or support the expression of emotions.
The most common interventions involve combinations of: education/information, listening, (re)
gaining control, exploring (thoughts, feelings, coping mechanisms, own solutions, support net
work), structuring, clarifying, non-directive advice, instruction, behaviour change (e.g. skills),
working through of emotions (controlled, gradual exposure), working on acceptance and on
future perspectives.
In addition, other elements of health (physical, social, spiritual, moral) are addressed: referral to
health services, social services/NGOs (for practical support, distraction activities, income
generation), involvement of support network, collaboration with traditional or spiritual healers,
or use of personal and family rituals (e.g. visiting meaningful places, family gatherings).
Lastly, advocacy or alerting authorities and local leaders about a problem can contribute to the
effects of treatment (e.g. increased protection).

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

Tbl. 15 Overview of supportive counselling interventions in MSF psychosocial, mental health projects
Supportive Counselling

Treatment/Support

Remarks

Medical setting
Psychosocial problems

Aim of medical setting: to recognise and normalise


psychosocial reactions, to allow expression of emotions,
and to reinforce existing coping mechanisms or to
provide advice about adequate coping behaviour
Active listening
Controlled expression
Problem structuring
Education or information
Enhancement self-control
Helping the client to make their own decision
Restoration of daily activities
Stimulating social activities/distraction

Skills of basic medical


training are sufficient
Extra knowledge
available through
guidelines or
field training

Counselling service
Most common areas of intervention:
Practical problems
Lack of social skills
Symptoms, complaints &
behaviours
Overwhelming feelings
Inner conflicts

Aim of counselling: to increase psychosocial functioning


of the client
Mental health
Education/information
Listening
(Re)gaining control
Exploring (thoughts, feelings, coping, own solutions,
support network)
Structuring
Clarifying
Helping the client to make their own decision
Instruction
Behaviour change (e.g. skills)
Working through of emotions (controlled exposure)
Working on acceptance and future perspective

Counsellors receive
ongoing training
Clinical supervision is
mandatory
Focus on main complaint
or dysfunction
Maximum 15 sessions
(often 3)
Principles of brief therapy

Physical, Social, Spiritual, Moral health


Referral to health services
Referral to social services/NGOs (for practical support,
distraction activities, income generation)
Involvement of support
Collaboration with traditional or spiritual healers
Use of personal and family rituals (e.g. visiting
meaningful places, family gatherings)
Advocacy or alerting authorities/local leaders
(e.g. protection)
Role of counsellor 112
Practical problems: counsellor helps people to think
about and to find resources
Lack of social skills: counsellor is a teacher and trainer
Complaints & behaviour: counsellor is specialist in
identification and provision of support for people with
psychological consequences of violence
Overwhelming feelings: counsellor is a listener
and comforter
Inner problems: counsellor explores problems and
feelings in the context and helps the client to
understand himself better and to make choices

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

49

E.4

Children

E.4.1 Basic interventions


Basic interventions aim to support the normal coping process of children. In most circumstances
it is useful to consider the child as a part of the (family) system. Subsequently, both the child and
the caregiver should receive support. Otherwise the child might become isolated from the
(family) system.
A system approach does not necessarily mean that child and caregiver receive treatment
together.There are several reasons why it might be best to start with separate sessions:
The parents may have their own traumatic experiences that need care.
Feelings of powerlessness and fear associated with the parents inability to protect their child
from the traumatic experience need attention.
Children may want to protect their parents from the events, fears and other feelings they have
experienced and thus not reveal their emotions in front of them.
Separate sessions may provide the child a better opportunity for self-expression. Of course, if
the child wants the caregiver to be present, this wish should be respected.
Providing support to children in groups is useful. Children can learn a lot from each other and
provide mutual support.To be part of a group enables the child to increase social interaction
and receive recognition. However, the composition of the group needs careful attention.The
counsellor has to be sure that the child can participate as an equal member and that their
behaviour does not disrupt the group. Furthermore, one needs to consider to what extent a
childs stories may harm others. Children and their caregivers with severe traumatic experiences
should first receive individual support.
To stimulate the normal coping of the child several things can be done.
Physical support:The child must be protected. When this fails, support has to be provided.The
provision of other basic material such as medicine, nutritional supplementation, water, shelter is
also essential for the childs physical survival.
Psychological support: The child needs to re-construct the events related to the traumatic
experience. By re-conceptualising it in a new light, the child can create order and ultimately
regain control.This can be facilitated in a basic health care centre, in the caregivers home, or
even in schools. Playing or drawing are appropriate methods to stimulate a childs
reconstruction and gaining of control, because verbal expression is more difficult for them.
When a sense of personal control is re-instilled, and a greater understanding of the traumatic
event is reached, the content of the play or drawing will change.
Reconstruction can happen naturally for instance through post-traumatic play or under the
guidance of a trained counsellor who is clinically supervised. Especially for children suffering
from nightmares and flashbacks it is necessary to improve their knowledge on these
symptoms and on how to exert control over them.
The counsellors role is to help the child restore control if the process of reconstruction is too
painful. Initially the counsellor should try to mobilise existing coping mechanisms. Other methods
like relaxation and distraction can also help to increase control.
The child and caregiver must understand that the process they are going through is unpleasant
but normal after such experiences. Counsellors should provide tips on how the child can deal

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

with unpleasant thoughts or feelings and manage his fear. These tips should be explained in
simple language, and build on existing coping mechanisms from a childs past.
The child and caregiver should also establish a daily structure of routines and activities.This
should include activities that help the child to distract him/herself.
Identification, monitoring and follow-up of children at risk should be on-going.
Social support: In addition to providing several practical arrangements the stimulation of
contact with peers is important. Within the limitations of the confidentiality a childs social
circle needs to understand what is going on.
Caregivers must be informed about how to support the childs coping process. Special
attention should be given to caregivers themselves, since it is not easy to deal with a
traumatised child. It is important for caregivers to understand how the childs condition can
influence the caregivers behaviour. If appropriate, relate this behaviour to the caregivers own
traumatic reactions provoked by the traumatised child.
Tbl. 16 Overview of basic interventions in the management of traumatised children
Stimulate normal coping activities
Physical

Arrange protection and/or support network of the child


Provide (or facilitate) practical support for basic needs of the child (e.g. medical care, nutrition, water, shelter)

Mental

Social

Activate social networks


Educate caregivers about what is going on and what they can do
Increase the caregivers insight into his own reactions
Inform other professional groups about possible reactions and behaviour of children

Help to understand and create order


Normalise: explain reactions as normal
Provide tips about how the child can deal with unpleasant thoughts or feelings, manage fear
Stimulate return to daily routines and activities
Organise or refer to distraction activities
Identify, monitor and follow-up children in risk groups

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51

INTERVENTIONS AT THE COMMUNITY LEVEL:


THE SOCIAL COMPONENT

F.1

Acute emergencies
Community services in acute emergencies focus on the provision of direct care for the purpose
of ensuring survival.

F.1.1

Practical support: provision of health care and basic materials


Refugees and internally displaced populations are usually not prepared for their flight, and thus
have many practical needs. Health care is provided in nearly all emergencies. In acute
emergencies the provision of basic materials like plastic sheeting, hygiene materials, and food
need consideration. Water and sanitation activities further improve the basic health of the
people.
It is impossible for one single humanitarian actor to care for all practical needs like food, family
tracing etc.Therefore, cross referral to other agencies or increasing awareness of other services
are part of the practical support given.

F.1.2

Information centre
Information is in certain circumstances vital for survival, and for stress or panic reduction such as
chemical/biological warfare, epidemics, highly contagious illnesses (e.g. Ebola). Information centres
are used to disseminate information about health related issues and to give practical information
(where to find what). Furthermore, the centre is used for monitoring protection and
humanitarian affairs issues. In later stages the information center can be the base from where
distraction activities are started.
To avoid rumours or misunderstandings in the population, and to build trust, information
management must be transparent, strict and consistent. Cooperation with respected members
of the community like teachers and religious leaders improves local acceptance and validity,
and ensures information is given in an understandable and culturally appropriate manner.

F.1.3 Group debriefings


Over the past decade large group debriefings to prevent psychological consequences of
violence have become popular. In emergencies this approach is tempting since it assumes that
large numbers of people can be assisted with limited human resources. However, this approach
requires serious reconsideration. Firstly, if the debriefing is done in larger groups (more than
fifteen) management of emotions may become problematic.The risk of re-traumatisation or
ventilation of despair without proper attention is high. Furthermore, the beneficial effects of
specific methods like Critical Incident Stress Debriefing113 in which the group of victims are led
through seven stages in a single 1 to 3 hour session, are at best doubtful.114 While some
debriefing methods as described by for instance Raphael115 and Dyregrov116 seem to improve
symptoms of PTSD, it remains uncertain whether there is a significant difference in the
prevalence of PTSD between populations that have been debriefed, and those that have not.117
This is due to the fact that studies have identified the prevalence of PSTD in terms of its

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

symptoms, and not by its effects on other processes such as grieving and substance abuse.118
Therefore, large group debriefings as an intervention strategy are not recommended.
A useful alternative is a health education approach in which emotion ventilation is limited and
contained.The focus is on self-control and self-help. Large group education is an approach that is
more often used in chronic crises, see Community Mobilisation and Health Education F.2.3.
F.2

Chronic crises
Community mobilisation and education can be used to stimulate the existing coping
mechanisms of large groups. Socially and culturally appropriate methods should be employed to
stimulate social support and self-help (e.g. peer groups), and to re-establish self-control among
community members.x

F.2.1

Practical support
The practical needs of the chronic emergency are usually different in nature as people try to restart their daily live and activities. Some practical needs like water and sanitation and medical
care are provided.To cover other practical needs it is important to involve and refer to
community networks and NGOs.

F.2.2 Community mobilisation


Conflict nearly always affects the social fabric of a community. After mass violence the
regeneration and revitalisation of new or former community structures often requires assistance
from outside. Cultural leaders like chiefs, religious leaders, the elderly must be stimulated to reassume their roles. Grass roots initiatives need assistance and stimulation. Several steps must be
taken to ensure effective community mobilisation:
Identify the purpose: Community mobilisation is an appropriate tool to stimulate community
regeneration, and can serve a wide variety of project purposes. It should be used to increase
knowledge about important health issues such as malaria, traumatic stress, and awareness
about the availability of health and psychosocial services. Community mobilisation can be used
to explain health activities such as mass vaccination, to encourage social cohesion through
distraction activities, and to stimulate awareness about local organisations such as grass roots
groups for women.
Situation analysis: Once the purpose of community mobilisation is clear, a situation analysis can
be executed to clarify operational issues, such as: what knowledge is needed, what information
is already known, what attitudes or reasons influence local behaviour, what mechanisms are or
were used to spread information within the community and with whom to cooperate. An
important part of the situation analysis is the definition of the target group (general
population, specific groups). Social issues (e.g. age, gender, taboos), security (e.g. gathering of
large group possible), as well as personal safety in the group (e.g. marginalisation or
stigmatisation), influence the selection of the target group.

x In this paragraph most of the material has been taken from: Shearer, A. (2003). Community mobilisation and health education. MSF internal publication.

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53

Define mobilisation strategy: An appropriate community mobilisation strategy should be


defined after the situational analysis. In general one of the following three strategies should be
chosen:
A top-level approach is appropriate if the involvement (and accountability) of the
authorities is wanted. Formal health authorities and informal actors such as chiefs,
religious leaders should be asked to mobilize the target group.
If the target group is mobilized through community groups like youths, sport groups
or specific community networks such as womens groups, schools the middle-level
approach is applied.
The bottom-up approach, also called do it yourself implies that the mobilisation is
conducted entirely through ones own mechanisms, such as going from door to door,
using gathering places like markets or health clinics, or organising discussion groups in
the community.
Choose the method of mobilisation.This can vary from simple methods such as songs, slogans,
banners, messengers to high tech methods like radio, newspapers.
F.2.3 Health education
Health education is an effective method for dealing with the mental health and psychosocial
consequences of violence.To compose the content of the message a situational analysis as
described above (see section F.2.2 on Community Mobilisation), is needed. The involvement of
the beneficiaries in the assessment, design and content of the health message is essential. Health
educators must speak the local language, use the appropriate symbols, understand local
sensitivities and dynamics and know how to approach the people. Only through their
involvement can a culturally appropriate method be ensured.
Health education messages should accomplish the following:
Provide information about (culture specific) psychosocial and health problems caused by
violence in the community: Firstly, members of the community must be able to understand
and identify the symptoms of mental health or psychosocial problems, behaviour and mental
conditions associated with trauma.This will result in enhanced acceptance and normalisation
of the psychological consequences of violence. It will encourage people to seek appropriate
care and lessen stigma/taboos associated with mental conditions.
Provide a comprehensive health message:Violence has adverse effects on life-style behaviour
such as smoking, substance abuse, aggression. Health education messages should include
general information about rules for healthy living. Specific messages about psychosocial topics
for instance stress can be easily combined with other health care messages (e.g. HIV/AIDS,
hygiene). A broad contextual perspective on health education decreases psychosocial and
physical morbidity.
Stimulate individual or community self-help mechanisms: Health education must increase
knowledge and skills for self-management among beneficiaries: how did the individual or
community help themselves in the past, how did people help each other in the past, what is
currently done, how do we think they can help themselves and how they can help others?
Improve self-monitoring: Community members need to know when they should look for
further support and what this entails.

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

Provide information about back-up services: It often does not make sense to increase
awareness about certain health issues if there is no follow-up support. If health education
is given about issues that have strong psychosocial or mental health components such as
traumatic stress, sexual violence, appropriate referral services like medical staff, psychosocial
support or mental health services must be in place. Where to go for further support must
be part of the health message.
Health messages must appeal:The more fun the message, the more people will listen and
the more they will remember. Engage the audience in health education. Interact with the
group when problems or solutions are explored, or use cultural elements like (street)
theatre, role-play, poetry, story telling, folk dances, drawing exhibitions etc. to disseminate
the health message.
Materials for distribution such as leaflets, posters etc. should be designed in collaboration with
the local population.
Tbl. 17 Overview of community mobilisation and health education
Steps for Community
Mobilisation & Health
Education

Comment

Define specific objectives

Situational analysis

Target group: general population, specific groups (considerations include: security, gender
and individual safety e.g. stigma)
Operational topics: determine what knowledge is needed, what is already known, what
attitudes or reasons influence the behaviour, what mechanisms are or were used to
spread information, with whom to cooperate, and where to refer

Strategy

Local people design message and material


a.Top-down approach
b. Middle level approach
c. Do-it-yourself approach
d. Bottom-up approach

Method of mobilisation

Low tech (e.g. songs, slogans, health clinics)


High tech (e.g. radio, newspapers)

Content of message

Make it pleasant

Interact with the group (avoid lecturing)


Include culturally accepted ways to disseminate message (e.g. theatre, songs, role plays)

Improve understanding
Reduce unhealthy behaviours
Improve knowledge/skills (self-control & self-help)
Improve social cohesion
Improve awareness about availability of services
Promote local organisations

Integrate (physical & mental) health care messages


Provide information about situations, signs etc.
Stimulate self-help
Improve self-monitoring
Provide knowledge about availability of back-up services

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55

F.3

Networking
Networking is essential for understanding and addressing the needs of a local population. It
involves establishing and maintaining relations of trust with relevant members of a population,
including community and spiritual leaders, representatives of vulnerable groups and local and
international NGOs. Networking is done with a long-term perspective and must be beneficial to
all parties. It is particularly useful to:
Mobilize and support local self-help mechanisms;
Increase the referral capacity of a project by connecting it to existing local care systems (e.g.
womens groups, income generating projects);
Negotiate with beneficiaries the service delivery.
Local informants can be helpful in developing culturally accepted approaches that improve the
delivery of support.

F.4

Distraction activities
Relaxation, meaningful activities and enjoyment contribute to the adaptation process after a
traumatic event.The feeling of being a member of some form of community helps people
restore daily functioning. Organising distraction activities can contribute to this. Some examples
of distraction activities include:
Cultural activities like traditional dance, exhibitions, drumming, music concerts, street theatre
and story telling. As the name says these are based on the culture of the people.They are
often very appreciated because they give the spectators a sense of belonging and continuity.
Physical exercise such as soccer, dancing, clowning and acrobatics improves relaxation and
promotes social interaction.
Occupational activities like for instance camp cleaning, jointly cooking, teaching children,
labouring the land, repairing or maintenance and caring for vulnerable people, are useful for
increasing ownership and improving self-control.

Tbl. 18 Overview of social activities

56

Social activities

Examples

Acute Emergency
Practical support
Information centre

Health care, food, water & sanitation


Contextual information, health messages

Chronic Emergency
Community mobilisation/Health education
Networking
Distraction: - Cultural activities
- Physical exercise
- Occupational activities

Hygiene, stress, prostitution


Leaders, local groups, NGOs
Folk dancing, music concerts, storytelling
Soccer, dancing, clowning
Camp cleaning, teaching children, building

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

INTEGRATION OF SERVICES

G.1

Justification
Approaches focusing only on the psychological, physical, or social dimension of the clients
experiences have limited value. A separation between these entities assumes, incorrectly, a
separation of body and mind, or the human from the environment.This separation does not
hold for Western medical-philosophical reasons nor is it in tune with non-Western worldviews.
Consequently medical interventions need to have psychological and social components, even
in emergencies.
The sense of such approaches is reflected in the integration of psychosocial or mental health
components in basic health care programmes through joint logical frameworks, an attitude of
comprehensive medical thinking (patient instead of disease oriented) and an integrated
management style.

G.2

Medical staff
Medical professionals like community health workers, nurses and medical doctors come into
regular intimate contact with the emotional and psychological worlds of their clients.The
curative and palliative role of the practitioners cannot simply end with the provision of technical
support. Providing emotional support is critical to a comprehensive treatment process that takes
into consideration peoples psychological, social, spiritual and moral functioning. It involves being
compassionate about peoples feelings, applying basic communication skills and sharing
knowledge on, for instance, techniques for recovery from the psychological consequences of
violence. Providing emotional support to a client directly benefits the healing process and does
not require a specialist.

G.3

Integrated Programming

G.3.1 Basic health care setting


Psychosocial care components are integrated in a variety of ways in basic health care services
(see Figure 7). When the provision of emotional support given by the medical staff is insufficient
to meet the psychosocial needs of a client, referral to other existing psychosocial services may be
necessary. Clients should only be referred to non-MSF services that have been quality-checked
by the medical team.
In the absence of local psychosocial support services a trained local counsellor or expatriate
mental health specialist can take the case referrals.
When the psychosocial needs overwhelm the existing local or expatriate services, a communitybased psychosocial component is implemented.The component has to be integrated into
existing Ministry of Health or medical services provided by an international NGO.
Psychosocial activities should also be linked to other types of medical activities like nutritional,
HIV/AIDS, health education, sexual violence, reproductive health, safe motherhood and
tuberculosis programme activities.
To achieve this a comprehensive medical attitude must be combined with integrated
project management.

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57

Separate interventions by MSF are considered in the following circumstances:


Acute emergencies;
Areas where conflict related psychosocial needs are high and no other medical needs have
been identified;
Contexts in which the local health system is functioning but unable to address significant
psychosocial needs caused by mass violence;
Very insecure areas in which independent project control is the only option to have a presence.
Fig. 7

Levels of psychosocial integration in basic health care programmes


HIGH PREVALENCE
Human resources:
Trained national staff counsellors
Trained national community health workers
Clinical supervisors (national or expatriate)
Individual and community psychosocial care:
Counselling
Community education
Practical support
Community mobilisation
Advocacy
Community activities
INCREASED PREVALENCE
Human resources:
Mental health specialist (national or expatriate)
Use of counselling skills & techniques:
Expression & structuring
Gaining control (exposure, education, advice)
Working through emotions (anger, guilt shame)
Acceptance
Future perspective
NORMAL SETTING
Human resources:
Medical staff
Intervention of medical staff focusing on:
Medical care
Basic psychosocial care (E.g. active listening, expression, normalising, self-control, advice & psycho-ed., daily activities)
Crisis intervention (e.g. structuring, here and now, relaxation, panic management)
Advocacy & Protection
Referral

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G.3.2 Psychosocial services in nutrition programmes


Malnutrition is often caused by a lack of access to food or health care induced by violence, lack
of protection, neglect and marginalisation.
Malnutrition (e.g. kwashiorkor119) affects mental functioning directly by causing lack of
concentration, disinterest and unclear thinking (confusion). Also, poorly balanced diets low in
vitamins, minerals and essential fatty acids are related to antisocial behaviour, including violence.120
Several vitamin deficiencies such as vitamin B3 are related to depression while others such as
vitamin C, vitamin D, and some B-vitamins cause generalised body pains.121
The relationship between nutrition and mental health is reciprocal. A serious depression or
traumatic experience is associated with a lack of appetite, and a decrease in lactacy of breast
milk.122 Even when food is available some people do not care to take it because they have given
up hope and the will to live. In addition, trauma increases family problems (including alcoholism).
The close relationship between the two must be reflected in the set up and management of
feeding programmes.123 Important for the feeding centres is the impact of traumatic exposure
on the caregiver-childxi interaction. In emergencies this is under heavy strain for several
reasons.124 Firstly, caregivers often have their own experiences and losses to deal with. Attention
is diverted from others while being pre-occupied with their own experiences. Even more
complicated is the situation in which the caregiver-child interaction is deteriorated because of
unwanted pregnancy including pregnancies caused by rape. Lastly, caregivers face serious time
constraints because they also need to take care of obtaining daily essentials such wood, water
etc. in often-unfamiliar areas.
G.3.2.1 In-patient therapeutic feeding programmes
Severely malnourished children are initially treated for 6 - 30 days in a inpatient facility. As soon
as their condition improves the child (and caregiver) is referred to an outpatient component of
the therapeutic feeding programmes or directly to a supplementary feeding programme for
moderately malnourished children.
Psychosocial care is a essential element in inpatient therapeutic feeding programmes.
The intensity and type of support is related to needs, staff capacity and contex.
The staff in all therapeutic feeding programmes must provide basic psychosocial support such as
offering a listening ear if the caregiver wants to talk about what has happened. Basic play and
games for mothers and children are offered to enhance the caregiver-child interaction. Health
staff should monitor the emotional and psychosocial condition of both children and caregivers.
Worrying signs include: a lack of appetite or a failure to thrive. Distraction activities like games,
plays, and music should be initiated to improve general atmosphere.
The positive effects of a special focus on the caregiver-child interaction encouraging hugging of
the infant, promotion of nurturing skills, and organising small plays is proven to increase efficacy
of the nutritional treatment in emergency settings.125

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59

In areas of massive traumatisation an intense and more systematic approach is justified. Activities
in addition to those described above are started.The mental state of each child and caregiver is
screened systematically at admission.The counsellor or health staff may refer beneficiaries
directly to the counselling services if necessary. All newly arrived caregivers are briefed by
counsellors in groups on the available services, feeding programme and stress related issues.
Peer group activities for the caregivers are initiated to discuss all types of practical issues,
to provide education, and to share emotions or experiences. In these groups attention is also
given to specific problems such as the challenges caregivers might face when they re-enter
normal life. Often these groups continue to support each other after dismissal from the
feeding programme.
Group counselling and individual counselling sessions are made available to help caregivers with
specific psychosocial issues.
Trained counsellors work under clinical supervision of mental health or medical staff. Often the
number of clients in need of intensive psychosocial support is high and the services need to be
staffed with a mental health expat.
G.3.2.2 Outpatient feeding programmes for severe and moderately malnourished
The later stages of treatment of severe malnutrition and the treatment of moderate
malnutrition is often organised on a outpatient basis.The patient is seen once a week or even
bi-weekly.These programmes have an outreach system to trace defaulters and identify new
cases of malnutrition.
The health staff doing the weekly medical checkups and the outreach staff should be trained in
recognising psychosocial problems, especially when a child is not gaining weight. In famine
situations, outreach workers should be alert for abandoned children, disabled or elderly, and
people who withdraw from social life or are afraid to leave their house. Health education should
inform people about the possibility to get psychosocial support and organise referral possibilities
to for instance food for work or free food programmes.
Finally, a balanced diet in hospitals and psychiatric institutions will improve the mental state
of the patients. As with other medical activities, food and nutrition support increases efficacy of
the treatment.

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Tbl. 19 Overview of psychosocial activities in nutrition programmes


Type of programme

Prevalence
psychosocial needs

Psychosocial activities

Inpatient:
Therapeutic Feeding Programme
Paediatric ward in hospital

Low

Basic psychosocial care:


Monitoring of emotional condition child (adult) and
care giver
Providing a listening ear
Be alert for survivors of sexual violence
Stimulation caregiver-child interaction
Play & distraction activities
Train health staff in recognition of mental health
problems and basic communication skills
Screening
Group briefings on services, feeding practices, stress
Peer groups (for practical support, education, and
sharing)
Individual and group counselling

High

Outpatient
Ambulatory treatment (part TFC)
Supplementary Feeding Programme

Low

High

Outreach: identification and monitoring


Basic psychosocial support (medical staff)
Health education including awareness psychosocial
support
Monitor mental health problems (failure to thrive)
Referral possibilities
Awareness among community leaders and stakeholders
General Health education
Counselling support
Community activities

G.3.3 Psychosocial services in tuberculosis (TB) programmes


Tuberculosis programmes are increasingly being implemented in conflict areas.The treatment of
clients and prescription of drugs requires frequent client contact to ensure adherence and
compliance to the regimen. Long hospitalisation, up to twelve months for Multiple Drug
Resistant TB, allows for regular contact between medical staff and the client. It provides an
opportunity for helping people with any psychosocial and emotional problems related to their
disease or causes that predisposed them to it.The integration of psychosocial services is even
more pressing because adherence to drugs is closely related to psychological and social health.
Several client problems are observed regularly. Clients may be traumatised; worry or feel guilty
about their family; cease to take their medication; experience unbearable side-effects from
treatment; exhibit disruptive behaviour due to drug side effects such as cycloserinexiii or
boredom; become lethargic or alcohol dependent; react to lack of privacy and freedom; and be
subject to stigmatisation and marginalisation. Furthermore, clients may have serious psychiatric
disorders and/or co-morbidities associated with previous traumatic experiences or HIV/AIDS.
In addition to proper medical and psychiatric care, psychosocial support is helpful in, for
instance; the provision of information and support to clients and family members; in the
exploration of motives for medication refusal or adherence problems; in helping people with
emotional problems like isolation and home sickness; in the management of aggression; in the
re-establishment of a daily routines and patient re-activation in the inpatient facilities.
The psychosocial care is provided as part of the basic care or provided by specially trained
health staff or counsellors.
xiii Cycloserine is only used in the treatment of Multiple Drug Resistant TB

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Tbl. 20 Examples of possible psychosocial problems and interventions in TB projects


Possible problems

Psychosocial activity responses

Client ceases to take medication

Provide information to clients and family

Client exhibits disruptive behaviour

Assess the reason behind behaviour

Treatment causes unbearable side-effects

Crises intervention techniques (e.g. relaxation exercises)


Drug therapy, medication adaption

Emotional problems related to past and


present situations or experiences

Provide individual counselling

Alcohol abuse

Provide behaviour change support


Organise support groups

Boredom, lethargy, lack of motivation

Stimulate daily routines that address cognitive, social and physical needs
Initiate activities in the hospital
Provide distraction material
Initiate group activities

Psychiatric disorder

Monitoring, early detection


Stabilisation
Drug therapy

HIV suspect

Refer to medical services


Pre-test counselling & testing
Provide post-test and follow-up counselling support

G.3.4 Mental health and psychosocial care in HIV/AIDS programmes in unstable


or conflict environments
G.3.4.1 Justification
The HIV/AIDS pandemic may spread more easily in conflict and lawlessness settings.
This section does not intend to give a detailed technical description of mental health and
psychosocial support for people living with HIV/AIDS. Such information can be found in other
relevant literature.126
The aim is to provide an overview of areas in which psychosocial and mental health support is
vital for those infected with, and affected by the virus.This section outlines a comprehensive,
community-based and integrated model of care for people living with HIV/AIDS. While this
comprehensive approach is considered important to effectively meeting clients and caregivers
psychosocial and mental health needs, it must be noted that:
It is not always desired or possible to implement the full range of activities (e.g. depending on
the security circumstances or lack of resources);
It is not always necessary to implement a comprehensive model because local grass roots
organisations, local NGOs and peer supports are often already reasonably well-organised.
Programme activities may therefore act to compliment or support already existing local
HIV/AIDS programmes to ensure complete access to comprehensive care.

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G.3.4.1.1

Mental health disorders related to HIV/AIDS


The HIV-virus penetrates the Central Nervous System at an early stage (day 16),
via macrophages that cross the blood-brain barrier.The virus affects only the microglial
cells and not the neurons. Nevertheless, both neuronal dysfunction and psychiatric
disorders are very common in people infected with HIV.127
Many HIV infected persons suffer sooner or later from a temporary psychiatric disorder,
especially when they become symptomatic.128 This may be explained by the fact that:
The psychiatric disorder may have existed before contracting the HIV virus. In some
cases this may have been a risk factor for contracting HIV/AIDS;
The psychiatric disorder was triggered due to a significant change in the status of the
person for instance shock of diagnosis, experience of first HIV-related illness, first AIDS
symptoms, stigmatisation by the local community, etc.;
HIV infection and AIDS pathology themselves increase vulnerability to psychiatric
disorders. Neurotoxins may cause neuronal dysfunction like neuropathy or changes in
gait.The brain and limbic system may become dysfunctional as a complication of AIDS
and cause complaints like: mood disorders, sleep disturbances, memory and
concentration complaints, mental slowing and agitation.
Psychiatric disorders commonly associated with HIV/AIDS are described in Table 21.
Differential diagnosis is often difficult because of co-morbidity such as combinations of
depression and anxiety disorder. It should be kept in mind that psychiatric symptoms are
also caused by physical factors, such as drugs side effects, or as interaction effects. Some
symptom expressions like trans-like states and psychosis are influenced by
cultural patterns.

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Tbl. 21 Overview of common mental health disorders associated with HIV/AIDS


Disorders

Brief description for details see DSM IV-TR,129 ICD-10130

Anxiety disorder

A person can be identified as having anxiety disorder if s/he has been worrying for a
period of six months and exhibits at least three of the following symptoms:
Restlessness or feeling keyed up;
Easily fatigued;
Difficulty concentrating or mind goes blank;
Irritability;
Muscle tension;
Sleep disturbance (difficulty staying, or falling asleep);
Clinically significant distress or impairment in social, occupational or other important
areas of functioning.

Mood disorders:
Depression & suicide

A person is considered clinically depressed if s/he has suffered at least 1 of the


following for the past two weeks:
Depressed mood most of the day (self reported or observed by others)
Markedly diminished interest or pleasure in all or almost all activities during the day
and if s/he has exhibited at least four of the following symptoms over the past
two weeks:
Significant weight loss (this must be compared to others in the same situation)
Insomnia or hypersomnia
Psychomotor agitation or retardation observable by others (not only a subjective
feeling of restlessness or slow down)
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Diminished inability to think or concentrate, or indecisiveness
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan or
suicide attempts

Manic disorder

Change in mood, exhibiting unusual and out of context happiness or irritability,


increased speed of thoughts, speech and behaviour
Loss of sense of reality
Disruptive and extravagant behaviour

Psychosis

Major disturbance of reality, involving hallucinations, delusions, incoherent thoughts


and marked deterioration in behaviour
Cultural expressions of local behaviours must be excluded.

Sleep disorders

Difficulty initiating or maintaining sleep, or non-restorative sleep, for at least 1 month.


A sleep disorder is not a psychiatric disorder!

Cognitive disorders:
Minor cognitive motor disorder
Dementia complex

Development of multiple cognitive deficits manifested by memory impairment,


aphasia, apraxia, agnosia,xiv executive functioning (e.g. planning) causing minor or
significant impairment in daily, social and occupational functioning.

Substance abuse

Prolonged substance abuse should lead to clinically significant impairment or distress.


A person can be identified as suffering substance abuse disorder if one or more of the
following occurs within a 12-month period:
Recurrent substance use resulting in a failure to fulfil major role obligations;
Recurrent substance use in situations in which it is physically hazardous;
Recurrent substance use related to (legal) problems (e.g. disorderly conduct);
Continuity of substance use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the substance

Delirium

Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.


It is directly and causally linked to brain dysfunction related to direct insult on the
Central Nervous System by a systemic or brain disease or endogenous or
exogenous substances affecting the brain.

xiv Aphasia: language disturbance. Apraxia: impaired ability to carry out motor activities despite intact motor function. Agnosia: failure to recognise or
identify object despite intact sensory system.

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G.3.4.1.2

Psychosocial problems related to HIV/AIDS infection


HIV infection affects all dimensions of a persons life: physical, psychological, social,
moral and spiritual. People who test HIV positive may experience a range of emotions
including denial, anger, despair and suicidal thoughts (or ideation). Strong emotions
and psychological reactions are not abnormal for people confronted with an
HIV-positive diagnosis.131
Special attention should be paid to issues surrounding stigmatisation. Stigmatisation of
HIV/AIDS in the community hinders the re-integration of the person affected by the
virus.This often leads to marginalization and isolation.
If the disease progresses, the client may be confronted with other psychosocial problems
caused by a high dependency on a support network, worries about himself and family
members, the confrontation with the symptoms of serious illness, and with death.

G.3.4.2 Treatment of mental health disorders: counselling and drug therapy


Psychiatric disorders usually respond well to treatment.The treatment of mental health
problems associated with HIV/AIDS often involves a combination of counselling (psychotherapy
if available) and drug therapy. Counselling is always considered first. If drugs are prescribed,
supportive counselling for the client and his support network improves treatment outcome.132
For more information on drug and counselling treatments, see Chapter E.
If drug therapy is applied a possible physical origin of the symptoms or possible drug
interactionsxv must be investigated.
The following points are considered when prescribing psychiatric drugs to people affected by
HIV/AIDS:
Start with a low dose, observe, and raise dosage slowly to avoid harm;
Polypharmacy is common among clients so review CD4, viral load, antiretroviral medication
(ARV), and other medication regularly;
Protease inhibitors: amprenavir, indinavir, lopinavir/ritonavir, nelfinavir, saquinavir (soft and hard
gel cap), generally inhibit metabolism of psychotropic drugs most notably: buproprion,
benzodiazepines, and clozapine; and
Efavirenz (sustiva) has frequent psychiatric signs due to its penetration of the Central Nervous
System.133 It can manifest itself through depression, confusion and nightmares.
G.3.5.3 Management of psychosocial problems: MSFs role in the continuum of care
Voluntary Counselling and Testing (VCT) is the main entry point for HIV-positive individuals into
a programme.VCTxvi and support services should preferably be located both on the community
level (decentralised VCT) and tertiary level (at hospital, or at an opportunistic infection clinic). A
functional relationship between community-based and governmental VCT initiatives is vital to
ensure access to comprehensive care. Figure 8 below shows in which areas a counsellor should
be involved.

xv Detailed up to date info: use www.medsape.com


xvi For detailed information see also: VCT guideline, MSF Holland, 1 June 2005

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65

Fig. 8

Overview of the links between the tasks of Voluntary Counselling and Testing (VCT) counsellors
and other services xxvii

Social services:
widow and
orphan care

Acceptance of,
and coping with
serostatus HIV

HIV campaigns:
awareness and
behavioural change

PLWA activism:
Destigmatisation
and normalisation

Peer support
groups for PLWHA

PMTCT

VCT

STI

Information,
education,
communication

Family planning and


condom distribution

Psychiatric and
pychosocial care

Medical care
(ARVs, TB, OI)

Treatment
Opportunistic
Infections

It is important to note that in the context of an HIV/AIDS project a counsellor is often referred
to as a VCT-counsellor.xviii Frequently, this results in a limitation and misconception of the
counsellors tasks: there may be a strict focus on the testing component and little follow-up or
emotional support.
It is strongly recommended by UNAIDS 134 that the counsellors role be expanded beyond VCT
services for several reasons:
The counsellor is in the unique position of establishing a close relationship with the HIVpositive person. A trusting relationship between client and counsellor has been shown to
positively influence behaviour change (safe sex, healthy living), the early identification of
symptoms, the facilitation of social functioning, and improved adherence135 to drug regimens;
If a counsellors professional responsibilities are limited to VCT, the counsellor is likely to
experience burnout or motivation problems.

xvii Adapted from: UNAIDS (2002). Report on the global HIV/AIDS epidemic. New York: Joint United Nations Programme on HIV/AIDS.
xviii Before being trained as a VCT counsellor people often have diverse professional backgrounds: medical (e.g. nurse, community health worker,
psychologist, psychosocial counsellor, mid wife) or non-medical (e.g. teacher, business man, etc.).

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G.3.4.3.1

Voluntary Counselling & Testing (VCT): psychosocial support


Lay, professional and senior counsellors should be trained to give information to people
who are considering taking an HIV/AIDS test, and to discuss their reason for coming
forward. An environment of trust and confidentiality is essential for the client to make
an informed decision.
If a person tests positive, the VCT counsellor should provide emotional support and
information about possible next steps of care.To manage the feelings of fear, anger,
profound sadness and shock of the client, the counsellor must have at least basic
counselling skills.
However, counselling is not limited to the post-test session. Follow-up sessions should
be offered to give additional information, for instance, about what to expect; future
planning and support groups; to discuss practical problems such as family planning and
condom distribution; or dilemmas like partner disclosure. Also regular emotional support
to help clients deal with grief, guilt, adjustment difficulties, physical and emotional
isolation, may be needed.The acceptance of the diagnosis and a positive emotional state
helps to combat the development of the disease.

G.3.4.3.2

Community mobilisation and outreach


The need for community mobilisation and outreach services in a programme depends
on the prevalence of HIV/AIDS in the community. In contexts of low prevalence this has
lower priority and it is more useful to focus on the mobilisation of the persons personal
support network.
In high prevalence areas, however, community mobilisation is important to prevent new
infections and to ensure a continuum of care. An active community approach that
includes education and awareness sessions creates an atmosphere of acceptance,
reduces stigma, and promotes self-help mechanisms such as post-test clubs. Community
mobilisation initiatives should be closely connected to health education, medical and
VCT services.
Outreach to vulnerable cases like isolated clients can be organised through post-test
clubs, peer and lay counsellors.

G.3.4.3.3

Adherence to anti-retroviral (ARV) therapy


The use of anti-retroviral (ARV) drugs can prolong the asymptomatic stages of HIV or
bring an AIDS patient back to an asymptomatic stage. Despite the significant reduction
of symptoms many patients find adherence to ARVs difficult.The initial, serious physical
side effects, as well as a poor mental health status (e.g. mood problems), may have a
negative influence on adherence to ARVs. Special ARV adherence groups should be
organised. Facilitators must have a basic understanding of counselling and group
processes. Professional and senior counsellors should have regular contact with these
support groups.Those with serious psychosocial or psychiatric problems must be
referred to a professional counsellor.

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67

G.3.4.3.4

Home-based care, and end-stage palliative care


Clients in the last stages of AIDS often become dependent on outside support, and
home-based care teams are essential to ensure basic physical and psychosocial care.
Individual counselling support and if necessary psychiatric care must be available.
It should focus on helping clients and caretakers to deal with chronic symptomatic HIV
infection and provide support in terminal stages of the disease (palliative care).The role
of the home-based care team and the counsellor is not only technical; it also provides
emotional support to both the client and the caretakers. Care includes making practical
arrangements following death.

G.3.4.4 Meeting the needs of specific groups and MSF staff


Some national staff like VCT counsellors may develop work-related psychosocial problems.
A Helping the Helpers system to provide psychological support to national staff is mandatory
for every HIV/AIDS programme, see section M.3.
G.3.4.4.1

Policy implications
The following practical and policy issues are especially relevant to VCT counsellors and
must be considered prior to initiating any comprehensive and community-based programme:
1. Determine to what degree comprehensive care is possible.
2. Ensure that counsellors are aware of all existing medical and social support networks
to appropriately support and refer clients.
3. In AIDS care, ensure that the counsellor works in the context of a multi-disciplinary
team (medical, para-medical and psychosocial support staff).
4. Integrate support services into other medical services. Parallel (or vertical) mental
health or psychosocial programs are not recommended in the context of HIV/AIDS
programs.
5. Provide psychosocial support in HIV/AIDS programmes by a (national) counsellor
together with specialist mental health professional (expatriate or national).
6. Ensure counsellors have full responsibility for:VCT (pre and post), and follow-up
supportive counselling in all phases of the disease.
7. Ensure that counsellors have a part-time facilitating role in post-test clubs, community
education, see also Chapter G.3.4.3.4, adherence, home-based and palliative care.
8. Train counsellors in both VCT and emotional supportive counselling skills.
9. Extend the training content and policy as described in Chapter K with specific
knowledge and skills required for VCT and specific HIV/AIDS related problems (e.g.
adherence).
10. Continue training during programme implementation.
11. Provide training appropriate to counsellors levels of experience and job description
within the continuum of care. (For an overview of qualifications, roles and
responsibilities of the VCT counsellors, see Table 22.)
12. Implement a staff care system in each HIV/AIDS programme (see also Chapter M).

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Tbl. 22 Qualifications, roles and responsibilities of (VCT) counsellors xix


Level and qualification of counsellors

Roles and responsibilities include

Senior counsellor
Has significant counselling experience and
advanced counselling training
Has knowledge of psychiatric disorders &
palliative care
Is experienced in the provision of training
& clinical supervision

Supervision and training of counsellors


Mentoring of less experienced counsellors
Provision of support and clinical supervision
Acceptance of referrals of difficult cases (psychosocial
and adherence)
Facilitation/supervision of adherence groups (occasionally)
Community networking

Professional counsellor
Has a professional background
(e.g. nursing, teacher)
Has received VCT pre/post training
Has received community education/facilitation
training
Is receiving ongoing (psychosocial) counselling
training on various psychosocial topics
Is receiving regular clinical supervision

Conducting of pre/post counselling for complicated cases


Couple counselling
Follow-up counselling
Adherence counselling
Support for home-based teams (e.g. palliative care)
Support for lay & peer counsellors
Occasionally facilitation/supervision of post-test clubs
Regular facilitation community education/awareness raising
Community networking

Lay counsellor
Has received VCT pre/post training
Is receiving ongoing (psychosocial)
counselling training

Peer counsellor
Has a similar background to clients (including
post-test negative, PLWHA)
Has attended an HIV/AIDS course (incl. Pre-test)
Has received basic community
education/facilitation training
Has received an introduction course to
(psychosocial) counselling

Advocacy and community mobilisation


HIV education and preventive counselling
Basic follow-up counselling of uncomplicated cases
Running/supporting of post-test clubs
Community outreach to vulnerable cases

Pre/post counselling of routine cases


Follow-up and supportive counselling for uncomplicated cases
Community outreach to vulnerable cases
Regular facilitation/supervision of post-test clubs
Community networking

G.3.5 Psychosocial services in projects addressing sexual violence


Sexual violence is an umbrella term used broadly to define violent sexual acts including: rape,
sexual slavery, forced prostitution, pregnancy, and sterilization. Rape is commonly used as a
weapon of war. MSF defines rape as any sexual act or penetration, of any kind whatsoever,
committed on another person by means of violence, compulsion, threat or surprise.136
Main risk groups are women, children, disabled people and prisoners.Though rape is mainly
associated with women, men are also subject to sexual violence. Our work in conflict areas
often confronts us with the consequences of sexual violence.
Rape has a large number of physical and psychological consequences in both the short and long
term.137 It is associated with a high prevalence of PTSD.138 Psychological consequences also take
the shape of other mental health disorders like depression, anxiety disorder or surface in less
obvious ways such as shame, guilt, fear, sleeping problems, difficulties in daily functioning,
withdrawal, sexual problems or relationship problems.
Care for victims of sexual violence must be available in all medical programmes.xx The type of
psychosocial services provided will differ in every context, and is determined by the prevalence
of sexual violence in the area.
xix Adapted from: UNAIDS (2002). Report on the global HIV/AIDS epidemic. New York: Joint United Nations Programme on HIV/AIDS.
xx For a detailed description see: Guidelines on the mental health and psychosocial support for survivors of sexual and gender-based violence. MSF (2005)

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G.3.5.1 In all medical programmes:


Medical care for survivors of sexual violence including prevention of HIV through Post Exposure
Prophylaxsis and unwanted pregnancy must start immediately.
Psychosocial and mental health assistance to survivors of sexual violence has been effective.139
The most basic psychosocial intervention is to prepare the survivors of sexual violence for the
physical examination. It is important to take time to explain what is done and why, to check
whether the person understands and to make clear that the person can stop the physical
examination at any given moment.
All health staff must be prepared to give basic psychosocial support to survivors of sexual
violence by:
Engaging in active and non-judgmental listening
Supporting (not forcing) the expression of emotions
Acknowledging and normalizing the reactions of the survivor
Providing psycho-education and advice
Encouraging self-control
Stimulating the re-initiation of daily activities
Giving attention to re-socialisation and/or affected family relationships
The skills to undertake these activities are part of regular paramedical and medical training.
Health staff must undertake these basic psychosocial interventions themselves as much as is
possible.
Panic attacks and high levels of anxiety are normal among survivors of sexual violence.140
Crisis intervention, for instance the structuring of thoughts, restoration of here and now,
relaxation and re-assurance, may be necessary.
In serious cases, referral to a specialist in the health system or to a local organisation specialising
in counselling may be necessary. Expatriates must verify the quality of local counselling services
prior to referring clients. Important criteria of quality include: regular training of staff, clinical
supervision, confidentiality and satisfied beneficiaries.
Advising referral on request of the patient to legal assistance or human rights organisations can
be part of the healing process. Here, verification of quality of referral services is also necessary.
G.3.5.2 In areas where the prevalence of rape is elevated:
In these situations, basic psychosocial support provided by health staff may be insufficient.
Medical staff may be overburdened with patients, or not have the expertise to provide intensive
psychosocial support for serious cases. Extra capacity is therefore needed, either through
referral to a local organisation (remember to verify quality) or through the extension of medical
services to include a psychosocial component. A trained local counsellor or a mental health
expatriate can provide the psychosocial care. Support in these circumstances should include
basic psychosocial support (described above) as well as specialised counselling such as cognitive
behaviour therapy.

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G.3.5.3 In contexts of mass rape


In these settings the creation of programmes focusing exclusively on sexual violence is avoided.
Psychosocial care for survivors of sexual violence should be integrated into existing or new
services such as reproductive or basic health care, as this increases accessibility for beneficiaries
and avoids stigmatisation.
MSFs basic health care centres extend their services to include a psychosocial support unit
where trained national staff counsellors work under a (expatriate) mental health professional.
Where sexual violence is widespread, the issue also needs to be addressed on a community
level. Community health workers can organise community activities (e.g. theatre) and health
education events to increase knowledge and awareness about health issues, including sexual
violence. Discussion groups may be formed for specific community members such as teenagers,
prostitutes or men for a targeted approach to changing attitudes towards sexual violence. It is
mandatory to actively involve formal and informal authorities such as chiefs and the elderly in
the process of awareness raising and fighting the occurrence of sexual violence.
Tbl. 23 Psychosocial support after sexual violence
Prevalence

Level

Staff involved

What to do

Normal prevalence
in each programme

Health clinic

Medical staff

Prepare for physical examination


Offer medical care
When necessary, train national staff on awareness
Offer basic psychosocial care (see Tables 12 & 15)
Advocacy
Refer to (local) psychosocial support service

Elevated prevalence

Health clinic

Medical staff

OPD or
Specific NGOs

National or
expatriate counsellor

Medical care
Basic psychosocial care (see Tables 12 & 15)
Train national staff (in awareness & intervention)
Intensive counselling support either individually or
in small groups (see also Table 15)
Focused education in medical facility
Advocacy

Health clinic

Medical staff

High prevalence

Community-based National trained


counsellors &
community health
workers

Offer medical care


Offer basic psychosocial care (see Table 15)
Train national staff (in awareness & intervention)
Train local counsellors
Offer intensive counselling support either
individually or in small groups (see also Table 15)
Raise community awareness
Offer community education
Community re-activation
Advocacy

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G.3.6 Psychosocial services in situation of Chemical and Biological Warfare (CBW)


Little research has been done on the physical and psychosocial effects of Chemical and
Biological Warfare141 (CBW).The World Health Organization (WHO) is in the process of
designing a document on the public health response to biological and chemical weapons.142 It is
generally assumed that CBW causes a high number of casualties.The reality, however, is that the
number of direct casualties from immediate exposure is often limited due to the highly
unpredictable contextual variables such as wind and rain.143 The long-term consequences of
exposure remain unknown.
The provision of psychosocial care is important not only in situations where CBW is ongoing,
but also where it is a threat. Psychosocial interventions can assist in dealing with individuals fears
and anxiety as well as in the mass management of social disruption.
G.3.6.1Supportive counselling in the threat of CBW
The threat of becoming ill through undetectable agents affects the basic human need for
control and predictability.Threat of CBW can cause profound excitation among authorities and
civilians, and trigger irrational and strong emotions among individuals. It often results in increased
alertness and the implementation of monitoring, preparedness and prevention activities on
behalf of individuals and the State. Social disruption like rumouring, chaos, scapegoating, paranoia,
denial and aggression, and augmented health complaints for instance caused by the
misinterpretation of bodily signs, somatisation and stress related complaints, can follow.144
Panic can seriously impair effective CBW monitoring and preparation interventions.145
Although experience shows that people generally act in a cooperative and adaptive manner
during crises, panic prevention mechanisms like structured, consistent information dissemination
are important.146 Expatriates should foster relationships with community leaders to efficiently
compose and convey information.
G.3.6.2 Mental health support in the aftermath of CBW
Non-governmental Organisations (NGOs) do not have the technical knowledge or capacity to
provide medical care in areas recently affected by CBW.The ability to initiate a mental health
intervention in populations affected by CBW depends on ongoing assessments of security and
on the proximity to biological and chemical agents.
After an attack by chemical or biological weapons, psychobiological reactions may be imminent.
Rapid, accurate triage and effective treatment including immunisation and containment strategies
are essential to cover the direct psychiatric and psychological consequences of exposure to
chemical and biological agents such as disorientation, depersonalisation, hallucinations or
delirium. In order to make an accurate diagnosis and intervention, it is essential to realise that
some biological agents have specific psychiatric/psychological effects, see Table 24.

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Tbl. 24 Neuropsychiatric syndromes or symptoms in biological agents


Biological Agent

Syndrome or symptoms

Comment

Anthrax

Meningitis

May be rapidly progressive

Brucellosis

Depression, irritability, headaches

Fatalities associated with central nervous system

Q fever

Malaise, fatigue
Encephalitis, hallucinations

In 1/3 of clients
In advanced cases

Botulinum toxin

Depression

Due to lengthy recovery

Viral Encephalitis

Depression, cognitive impairment

Other mood changes have also been reported

All biological agents

Delirium

Acutely impaired attention, memory and


perceptual disturbances

Exposure to chemical or biological weapons may also trigger psychological or psychiatric


complaints that are not related to the chemical or biological attack such as acute (traumatic)
stress, psychosis, shock, anxiety/panic disorder and unclear psychological signs as a result of
attention seeking behaviour. Appropriate interventions are described in the section on individual
support and treatment, see Chapter E.
Lastly, CWB can cause many types of psychosocial problems. Increased stress, arousal and
misinterpretation among a population, for instance as result of confusing autonomic arousal with
infections or intoxication, can seriously impede the functioning of the health care system.
Information and education about prevention and treatment options for exposure to chemical
and biological agents may be helpful in these circumstances.
G.3.6.3 Staff care
An extra consideration for situations of mass threat or attack of CBW is the management of
national and expatriate staff. Programme management must take into account:
Safety of staff, which includes proximity to chemical agents, and also the possible security risks
caused by the scarcity of evacuation possibilities or angry reactions of the host community;
Staff reactions directly related to exposure (e.g. impaired concentration and cognitive
functioning, disturbances in memory, over-dedication);
(Traumatic) reactions among staff caused by the exposure to panic or high mortality.
To manage these risks the project manager must monitor and assess the situation daily and
not depend solely on reports from the field. A Helping the Helpers service (see section M.3),
must be in place to identify and support staff affected by the direct or indirect consequences of
working in areas of CBW.
See Table 25 for possible mental health interventions in populations affected by CBW, according
to the phase of the emergency.

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Tbl. 25 Management and staff considerations for mental health interventions in populations affected
by Chemical and Biological Warfarexxi
Phase

Management and staff considerations

All Phases

Management considerations:
Assess security situation daily
Establish clear security and evacuations plans and procedures
Establish Helping the Helpers system (peer or professional psychosocial care-unit)
Address ambiguous situations by making strict rules for behaviour.This reduces stress and
enhances performance
Monitor work/rest cycles of staff, and watch out for masked symptoms and over-dedication
Organise regular, fixed drink breaks for staff to avoid heat casualties
Create openness between staff members and regularly discuss concerns about safety and
contamination
Institute a zero tolerance policy for alcohol in and around the working place
Be sensitive to staff problems, concerns, especially regarding exposure to low dosage CBW
If low dosage exposure is suspected, do not hesitate to immediately send people to an
outpatient department
Prepare for panic management:
Compose a preparedness plan
Disseminate structured and consistent information to community; build trusting relationships
with leaders and involve host community in composing and conveying information
Implement appropriate public self-protection mechanisms
Conduct ongoing community education about various health issues
Consider establishing an information centre

First Aid
(Outreach, triage
ground)

Management considerations:
Brief first responders on their security management and medical, mental health
case management
Staff considerations:
Bring clients to safety immediately
Prescribe anti-psychotic & anxiolytic medication
Use crisis counselling intervention techniques (e.g. containment)
Stabilise cases with acute traumatic stress
Inform clients or family about normal side effects of drugs
When possible involve family members in the care of clients

Second phase
(Basic health
care unit)

Staff considerations:
Prescribe anti-psychotic & anxiolytic medication (treatment simple and conservative)
Use crisis counselling intervention techniques (e.g. containment)
Stabilise cases with acute traumatic stress
Provide time and resources for emotional ventilation (or frank and open discussions)
Focused provision of psycho-education and information
Involve natural caregivers as client monitors
Organise (camp) outreach for medical and psychological cases

Stabilization
Phase

Management and staff considerations:


Run a psychosocial programme as described in chronic crisis (see section J.3)

xxi Activities highly dependent on security assessment and ongoing monitoring

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ADVOCACY
The combination of medical aid and witnessing is MSFs defining principle of humanitarian action.
MSF bases its advocacy on the direct experiences of beneficiaries in addition to medical data.
In psychosocial projects or components addressing the psychological consequences of violence,
mental health counsellors hear many powerful stories and, through their client relationships, have
access to information that is relevant for advocacy. However, the role of counsellor and a
person taking witness statements such as a humanitarian affairs officer should not be mixed for
several reasons:
The use of information derived from a therapeutic relationship for public advocacy is a
violation of confidentiality within the counsellor-client relationship.
One needs to remember that counselling is not concerned with discovering the truth or
reliable accounts of what happened, but with the perceptions of the client.
Clients may distrust counsellors pledge of confidentiality. Sometimes these are justified, given
the substantial abuse of psychiatry and mental health information in some contexts such as
the use of psychiatric institutions to hold political dissidents in ex-USSR or currently in China.147
Despite these challenges, witnessing and advocacy activities in psychosocial or mental health
programmes can facilitate a clients healing. If properly handled, as set forth in special
guidelines,148 advocacy can be an important part of the healing process. It can strengthen
beneficiaries coping mechanisms and help empower them.149
In order to acquire useful advocacy material, and to secure the clients healing process, some
directions need to be taken into account:
Expatriate staff must train all national staff on advocacy and witnessing.The purpose of training
is to inform and educate the staff about the organisation and advocacy, to review the content
and use of specific guidelines and to discuss local or cultural adaptations. All national staff should
be trained on the principles of confidentiality, including limitations in access to client files.
General programme information can be used for advocacy purposes.The use of data as part
of an advocacy strategy requires the involvement of headquarters line-management and
humanitarian affairs advisors.
Witness statements can only be taken if the initiative comes from the beneficiary. Counsellors
should not force clients to provide witness statements.
If a beneficiary wants to testify his story in the absence of a humanitarian affairs officer in the
project, expatriate staff together with national staff can examine advocacy options for the
client in the local context.
The beneficiary should receive supportive counselling during the advocacy process when
requested. Special care is required to avoid indentification of the witness.
Since community health workers are not bound to confidentiality by a professional code of
conduct (as is the case for other health professionals), the humanitarian affairs officer can
interview them about beneficiaries experiences.
MSF Advocacy Guidelines and management should be consulted prior to initiating any major
advocacy activity.

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75

Tbl. 26 General directions on advocacy in psychosocial/mental health programmes


General directions

Comments

Train national staff about witnessing and advocacy

Consider security issues beforehand

Train all national staff on principles of confidentiality

Consider the involvement of humanitarian affairs advisors


(at headquarters)

Persons other than the counsellor, client and supervising


mental health staff should not have access to any client files

Include this in the general training of counsellors and


community health workers

General data as produced by the psychosocial programme


can be used for advocacy in most cases

Exception in major research projects to review the


psychosocial care itself (research protocol)

Self expressed and spontaneous wishes of the beneficiary


to testify can be facilitated through referral to an
appropriate person/institute by the counsellor and mental
health expatriate after considering certain procedures

The use of witnessing statements (advocacy strategy)


must be developed in coordination with national and
international line management and national staff

Examine, at the level of the local context, what referral


options are available when beneficiaries express the wish to
witness or come forward

Beneficiaries providing witnessing statements should


receive supportive counselling during the process
when requested

Community health workers have no formal therapeutic role


and are not bound by confidentiality work ethics; the
humanitarian affairs expert can therefore interview them on
their working experiences.

National and international line management and national


staff should all be involved

Advocacy approaches can only be executed after careful


examination of MSF Advocacy Guidelines

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PART I1I
SPECIFIC TOPICS

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77

FIELD ASSESSMENT

I.1

Justification
Psychosocial assessments are prompted by needs in the field. It is preferable that the field teams
(including expatriates or emergency team members) should execute the assessment under the
supervision of the Medical Coordinator and with support from headquarters staff.To execute
an in-depth assessment, a person with experience in psychosocial interventions is needed.
The goals of a psychosocial assessment are:
To identify the physical and locally defined mental health needs of a population affected by
mass violence;
To research positive and negative coping and resilience mechanisms in the population;
To understand the factors that influence peoples access to health care (e.g. socio-political
and ethnic dynamics);
To discover the expected outcome of the intervention among the population (indicators of
success); and
To identify appropriate programme strategies.
Public health principles that aim at the highest possible health impact are not the guiding
principles for assessments. Particular focus is given to identifying the needs of vulnerable or
marginalised groups.Vulnerability of groups is defined in terms of morbidity (e.g. presence of
symptoms), mortality (e.g. suicide), exclusion from care, human rights abuses, denial of the
beneficiarys dignity and specific conditions that increase vulnerability (e.g. psychiatric institutions).
Psychosocial assessments range in duration from one day, in acute emergencies that require
immediate intervention, to three months in pre-established projects that require fine-tuning
and anthropological analysis.The average assessment lasts three weeks. Informal psychosocial
assessments should continue throughout project implementation to enhance fine-tuning of
the activities.

Tbl. 27 General characteristics of an MSF psychosocial assessment


General Characteristics

78

Who

Field teams
Final stage: person experienced in psychosocial components (in-depth assessment, intervention advice)

Focus on

Mental health and psychosocial consequences of mass violence

Perspective

Immediate support to survive or cope

Duration

Average: 3 weeks with exceptions (1 day in emergencies, specific topics: months)

Priority

Individual and group components (with priority given to the individual)

Target Group

Most vulnerable (morbidity, mortality, exclusion from care, human rights abuses, denial of their dignity,
specific conditions/situations)

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

I.2

Ethics
All staff involved in the needs assessment must respect the professional ethics and principles of
humanitarian medical aid.150 Those most applicable to the needs assessment are: do no harm,
awareness and respect for cultural or ethnic variation and concerns, and confidentiality.
To protect the rights of participants for survey studies (i.e. interview subjects), informed consent
is necessary. Informed consent has various criteria:151
Information about the survey and objectives must be clear to the participant
The procedures, time investment and possible remuneration must be clear
The participant should always be free to stop his/her cooperation
The benefits of the study for the community should be made clear
The use of data and the possible consequences for the individual should be explained
It should be clear to the participant that refusing participation will not have any effect on his
treatment or well being
Preferably, the participant should sign an informed consent paper
The process of obtaining information may burden or even emotionally upset informants. During
the assessment the need for information must be balanced against the potential harm it might
cause to participants. A useful criterion in dealing with this dilemma is to continuously ask
yourself: What is the relevance of this information for the overall analysis? The person or team
that executes the assessment is obliged to secure basic medical or psychosocial follow-up for
those participants in need.
Special support should be provided to national staff, such as translators, who may be exposed
to potentially harmful and emotionally upsetting stories. Such support includes: preparation,
limitation of exposure in time, provision of emotional support when necessary, daily operational
debriefing, and counselling support when necessary.

I.3

Assessment Approach and Principles


The implementation of psychosocial programmes in the context of international humanitarian
assistance is still a relatively new phenomenon. Although aid organisations are building on
operational knowledge to improve programme efficiency, several conceptual questions remain
unanswered.152 For instance, how is the clinical significance of suffering defined in both individuals
and in groups in the absence of culturally validated measurement scales? What is the relationship
between the prevalence of the problem and the functioning of the individual or group? How are
the concepts: clinical significance, healthy functioning, mental and psychosocial disorder,
translated in different cultures?
These conceptual difficulties impede the development of a universal assessment methodology
and complicate the development of survey instruments.The absence of clear cut-off criteria
such as morbidity or mortality figures may lead to discussions about the conclusions of
assessments.To limit and streamline discussions certain criteria of good practice have been
developed.The criteria below are useful to consider in situations of chronic crisis.

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79

I.3.1

Qualitative and quantitative methods


Each psychosocial assessment must combine qualitative and quantitative methods. Quantitative
methods provide objective, measurable data about a populations mental health and
psychosocial needs. Qualitative methods provide information about the subjective perceptions
of individuals in a population; they give information about the range, depth and meaning of
peoples experiences. Both methods are complementary to one another.

I.3.2

Assessment instruments
Each assessment must use at least two different quantitative and three different qualitative
instruments.The use of more instruments enlarges the scope, and improves the reliability and
validity of findings.

I.3.2.1

Quantitative instruments
Health care data and mental health statistics from health posts, clinics or hospitals
are the most easily accessible type of quantitative information.They provide a quick
overview about the extent of medical and mental health problems met by a health
system and any changes in prevalence.
Psychosocial Questionnaires153 are structured interviews used for the large-scale
appraisal of psychosocial needs in closed (camp) and open (community) settings.
They are used when medical data are unreliable, but substantial psychosocial needs
are expected. Design, adaptation and translation for local circumstances are required.
Psychosocial questionnaires provide insight into the events (exposure, witnessing), the
psychological impact (for instance through Impact of Event Scale (IES154)), the
prevalence of specific health complaints and stress (for instance through General
health Questionnaire 28 (GHQ 28155), Self Reporting Questionnaire 20156) and local
knowledge, attitude, and self-help mechanisms.
Symptom checklists like for instance the Hopkins Symptom Check List,157 IES, SRQ 20,
and GHQ 28 can be used to assess the prevalence of psychosocial stress symptoms
in a population. Symptom checklists are in general not validated for non-Western
cultural environments.There is no instrument that measures the complete range of
traumatic experiences of refugees.158
Self-completion questionnaires are useful to rapidly obtain specific information on
a topic.These short open-ended questionnaires are used to obtain information about
sensitive subjects.
Knowledge Attitude Practice and Behaviour studies are used to gather basic
information about local context.

I.3.2.2

Qualitative instruments159
Qualitative instruments are essential to understanding beneficiaries perspectives on the
local psychosocial consequences of violence in terms of health and functioning, on ways
of expressing emotional distress (including vocabulary used), on psychosocial self-help
(coping) mechanisms and on other sources of relief and expected outcomes of an
intervention among the beneficiaries.

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Literature review: review the existing background literature (e.g. on history or


anthropology) as well as previous assessment reports by other organisations.The use
of a good literature review avoids unnecessarily burdening beneficiaries and saves time.
Focus Group Discussion: is a technique to facilitate discussion about a pre-defined and
limited topic among a selected group of beneficiaries. It is an informal and fast way to
assess needs, to survey results (e.g. accessibility of health care) and last but not least,
to become familiar with local ways of thinking, opinions, perceptions of the
beneficiaries and suggestions for intervention.
Key informant interviews: Of the various forms of interview like in-depth, individual,
group and case-study interviews that exist, key informant interviews are obligatory in
psychosocial assessments. Several formats are available such as general interview,
psychosocial consequences of violence and coping mechanisms.These qualitative
instruments are easy to use and easily adapted to varying contexts regarding depth
and content.
Structured or checklist observation (direct, walking around or clinic observation) is an
ideal method to see whether people act as they say they do in interviews.
Diaries in which the client registers severity of complaints and rates his functioning are
used to further validate information.
Mapping: The relationship between the beneficiary and his environment is important
to consider in assessments and interventions. In order to gain more insight into several
subjects, the following techniques are used:
Participatory mapping:To discover individual perception on certain issues like
social dynamics, the beneficiaries draw how their community looks like;
Social mapping:The beneficiaries draw what internal and external social
resources are available;
Hierarchy mapping: Answers questions like: who is in power and who is
responsible for what? These environmental tools are helpful in the
identification of social, spiritual and moral resources and resilience
mechanisms. But the mapping method is also used for researching other types
of information such as how security information is disseminated.
Other tools: If time and security permit, other anthropological tools can be used to
gather detailed information about beneficiaries perspectives on mental disorder (e.g.
causation and symptomology), local health management strategies (e.g. religious
healing, herbalism, witchcraft) and the expected outcomes of a psychosocial
intervention. Several qualitative anthropological tools are available to achieve this. If
possible, these should be used at the beginning of an assessment:
Free listing can be used to access beneficiaries perspectives about prominent
psychosocial problems in the community and to identify vulnerable groups.
The inter-relationship between these psychosocial problems and vulnerable
groups can be understood through pile-sorting.This technique results in a list
of the most important psychosocial problems within a community.
Pair-wise ranking is then used to find out their order of priorities according to
the beneficiaries.

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81

A Venn diagram exercise is used to find out which group(s) must be included
to address the top priority problem.Through this exercise it should become
clear which people are most affected by the problem, who is responsible
inside and outside the community for addressing this problem, who (inside
and outside the community) is currently addressing the problem and with
which groups (or organisations) cooperation is required.
Workshop: it is useful in nearly all circumstances to organise a workshop with
beneficiary stakeholders to discuss the assessment. During the workshop a facilitator
should be present. He then offers assessment results, analysing the relationship
between problems (the problem tree) and what needs to be done (the intervention).
This is also a good opportunity to discuss how changes and results can be observed
and measured as indicators of success.
Dictionary: during the assessment, special words, definitions, expressions, symbols,
explanatory mechanisms and rituals related to psychosocial problems can be
described in a special file.
Tbl. 28 Overview of assessment methods and instruments

82

Quantitative Methods

Instruments

Always use:

General medical monitoring


Mental health statistics (for suicide also police registers)

Preferred (time dependent)


one of the following:

Individual symptoms of psychosocial stress: symptom checklist


Population survey: psychosocial questionnaire
Specific topic information: self-completion questionnaire (quick & sensitive
information), KAPB-study (in-depth knowledge)

Qualitative Methods

Instruments

Always use:

Literature (report) review


Focus Group Discussion (health needs, expression emotional distress,
psychosocial self-help (coping) mechanisms, other sources of relief, expected
outcomes of intervention)
Interview: key informant (e.g. general interview, coping mechanisms, outcomes
of intervention), other forms (in-depth individual, case-study interview) can
be considered.

Preferred (time & security


dependent) several of the following:

Validation: walking about, structured observation, diaries


Environmental resources/resilience: participatory mapping, social mapping,
hierarchy mapping
Language: dictionary
Beneficiary perspective: free listing, pile-sorting, pair-wise ranking,Venn-diagram,
workshop (results, problem tree analysis, intervention, expected outcomes)

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

I.3.3

Validation of information
To ensure the validity of information (especially from qualitative methods) various sources of
information are used. Expatriate and national staff from local, national and international
organisations should all be consulted, as well as staff from government health care institutions,
local care providers (formal and informal) and key people in the community.
It is evident that the beneficiaries themselves play an important role in this process. To what
extend they are included in the assessment process depends on the situation and the time that
is available.
Minimum information requirements for an assessment include different levels of suffering (mildly
and seriously affected), both genders, different age groups, various educational and social
backgrounds.The validity of the assessment increases when a variety of methods are used and
more beneficiaries from different social strata are included in the assessment.

I.3.4

Triangulation of data
Psychosocial suffering after mass violence is mainly caused by exposure to traumatic incidents
and environmental conditions (trauma severity).The psychosocial suffering is further aggravated
by the impact of the trauma severity on all segments of the individuals health (conflict related
health needs). However, individual, group coping and resilience mechanisms (resilience
indicators), or availability of resources dampen the overall impact of the traumatic exposure.
It is necessary to analyse a populations severity of trauma, conflict related health needs, their
resilience mechanisms and available resources to determine appropriate programme responses
(response intensity).
Triangulation is the use of different sources and methods to verify validity or to find the truth
when information is conflicting or inconsistent. Based on triangulated data a conclusion of the
assessment can be drawn.
It is important to note that triangulation adds value to the assessment. Psychosocial
consequences of violence cannot be reduced to sets of symptoms and signs. Especially in
contexts of chronic crisis the loss of functioning, the impairment and suffering of both individuals
and communities escape the medical nosology of symptoms and disorders. A comprehensive
view is required to increase understanding about the beneficiarys perspective and suffering. It
promotes our proximity and efficacy.

Tbl. 29 Criteria of good quality for assessments in chronic crises


Criteria
Methods

Both qualitative & quantitative

Instruments

At least 2 qualitative & 3 quantitative and more if time permits


Different instruments used to increase robustness and scope of findings

Validation of
information

Different groups: at least consult beneficiaries, health staff, local care providers, key community people
Different perspectives: consult various levels of suffering, different gender & age groups, various
educational and social backgrounds

Triangulation
of data

Use different sources and methods to analyse:


Trauma severity
Conflict related health needs
Resilience indicators
Resource availability

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83

I.4

Early warning and field assessment


Many populations in countries where MSF is working suffer mental health and psychosocial
problems stemming from mass violence. A high level or a sudden increase in the prevalence of
psychosocial problems may trigger the need for an assessment. A populations need for mental
health and psychosocial services is often suspected or inferred by a field team while working, or
while communicating with the health authorities and other relevant aid organisations.
A formal needs assessment is required to confirm suspected health needs, and to modify
project objectives accordingly. Any needs assessment consists of two steps: a general assessment
(by the field team) and an in-depth assessment (by a specialist).

Fig. 9

Overview of assessment topics and phases

OUTSIDE SUPPORT
PLANNING
When?

RESOURCES
RESILIENCE
Mental
Physical
Local NGOs

TRAUMA SEVERITY
Events, signs & functioning

International NGOs
Moral

Social

Spiritual

INTERVENTION
Who?
What?
How?
Success?

I.4.1

Target Population
Purpose
Activities
Indicators

Early indicators
The majority of early indicators are related to trauma severity such as high incidence of human
rights abuses described by clients.The most striking indication of increased psychosocial needs is
a high level of conflict related health problems like war wounded and cases of sexual violence,
mental health disorders such as psychosis, depression (suicide) and PTSD, and stress related
problems, for instance traumatic stress, psychosomatic complaints and sleep problems. Clients
often report and complain about changes in their social environment shown for instance
through increased levels of community violence, disharmony and conflicts, and about poor
recovery environment.

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

I.4.2

General needs assessment by the field team


The question to ask at this stage is:To what extent are the observed needs indicative of a
structural problem? A medical line manager can ask the team to substantiate their first
impressions of trauma severity and conflict related health needs. Quantitative information such
as general monitoring, mental health statistics; as well as qualitative methods like observation,
reports, key-informant interviews with clients, leaders, focus group discussion are used.
To understand the scope of the psychosocial problems experienced by a population, the
medical line manager and project team should also analyse information about the populations
resilience (i.e. ability to cope) and its resources or what supports the coping process.
The resilience indicators for physical health such as the absence of disease, disability, acceptable
living environment; mental health like the feelings of control; social health, for instance the
availability of social support; and the existing psychosocial resources should be compared with
the quantitative and qualitative outcomes on trauma severity and health needs (see Table 30).
There are no strict criteria for initiating a mental health or psychosocial programme.The
decision to initiate or scale-up the psychosocial care component of a project depends on
current project priorities, needs and resources. It is clear that in case of discovery of mass needs
immediate intervention has to follow. In other cases, a specialist continues the assessment (see
Chapter I.4), in the event of:
High indicators of psychosocial problems, low signs of resilience and poorly
developed resources;
Normal levels of psychosocial problems, low signs of resilience and poorly
developed resources; or
Marginalised or other affected groups (e.g. elderly, single parent households).

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Tbl. 30 Overview of factors important for early assessment and monitoring of psychosocial needs
Early Indicators & General needs assessment (field team)

Assessment Tool

Trauma severity (events)


Events (Context of mass violence, duration & frequency of events, proximity to event, life
danger, loss (people, material))
Recovery environment (displacement, socio-economic, poor quality housing/camp)

Quantitative
General health
monitoring
Mental health statistics

Conflict related health problems (signs and functioning)


Physical health (increased nos. of war wounded, sexual violence, stress related complaints
& morbidity,xxii mortality (infant, suicide), consequently unhealthy behaviour (e.g. smoking,
drugs, alcohol, STD, HIV/AIDS, abortion,) clinic attendance / return, placebo prescription)
Mental health (high levels of psychosis, PTSD, anxiety disorder, depression, substance
abuse, suicide (attempts), psychotropic drugs use, increased demand or use of mental
health services)
Social health (community disharmony e.g. conflicts, (family) violence, child abuse, vulnerable
groups e.g. marginalisation)

Qualitative
Reports
Focus Group Disc
Key informant interview
(clients, leaders)
Listening,
Observation

Resilience indicators

Resource availability

Physical health
Good health
Healthy behaviour
Physical activities
Favourable living circumstances

Functioning health services (formal and


informal)
Traditional healer

Mental health
No increase mental health pathology
Feelings of control
Previous ways of coping
Knowledge/information
Training/preparation
Social health
Social & emotional support
Ability to mobilise social support.
Cohesive community (caring capacity,
community sense, acceptance of
vulnerable people)
Active community member
Social structure/ order
Safety, security
Community in relative harmony
Continuation of traditional
activities/festivities
Respected leaders in the community
Self control (e.g. self income generation,
authority of significant leaders)
Self initiative (e.g. with regard to
camp/shelter organisation)
Self help

Mental health professionals (psychiatrists,


psychologists, social workers)
Psychiatric hospitals
Mental health policy & legislation
Traditional healer
Religious leader

Family/friends
Self help groups
NGOs (local & international)
Institutions (social welfare, schools,
work related)
Community leaders
Communal places & festivities

Quantitative
Health statistics
Number of mental health
specialists per 10.000
Policy document
Qualitative
Reports
Focus Group Discusion
Key informant interview
(clients, leaders, quality
mental health education,)
Listening
Observing

Response Intensity:
High:

continuous assessment in the event of:


High prevalence of psychosocial problems, low signs of resilience and poorly developed resources
Normal level of psychosocial problems, low signs of resilience and poorly developed resources
Marginalised or particularly affected groups
Insufficient time to finish/start the field assessment

Low:

stop assessment

xxii Increased (traumatic) stress complaints: headaches, sleeping problems, hypertension, palpitations, general body pains, short breath, hyperventilation,
(low temperature) fevers or local expressions of this.
Increased morbidity: cardio-vascular (e.g. hypertension), eczema, respiratory diseases (e.g. bronchitis), non-sexually transmitted diseases (e.g. peptic
ulcers, large bowel problems), pregnancy related problems, severely wounded.

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I.5

In-depth assessment
The objectives of the in-depth assessment are to confirm the findings of the general field
assessment; to further clarify the social, spiritual and moral health issues (signs and disruption,
resilience, resources); and to give advice on future intervention possibilities. A person with
experience in psychosocial programming should execute the in-depth assessment in close
cooperation with the field team management.

I.5.1

Problem tree
An in-depth assessment gives insight in the root causes of the problem(s), the effect it has on
individuals, the functioning of the community and appropriate project response.The analysis
results in a problem tree that shows possible causes, effects and relationships between the
various aspects of the problems and actors. If time permits it is useful to discuss the contents of
the problem tree with representatives of the beneficiary population.
The decision to add a psychosocial component to existing services (or in some circumstances
to start a vertical programme) depends on the outcome of the in-depth assessment and the
problem tree.

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Tbl. 31 Overview of factors important for an in-depth assessment of psychosocial needs


In-depth Indicators

Assessment Tool

See early indicators & general assessment: continue what is not finished

Quantitative
General health monitoring
Mental health statistics
Individual psychosocial stress
symptoms
Psychosocial questionnaire
Self-completion questionnaire
KAPB-study

Conflict related health problems (signs and functioning)


Social Health: community disharmony (conflicts, (sexual) violence, schisms, family
violence, child abuse); loss of cohesion (vulnerable groups, lack of caring capacity,
lack of trust, apathy, withdrawal); social disintegration (lack of social order, unclear
roles and leaders, status loss significant people, no self organising capacity,
disruption of customary/traditional activities); loss of self control (ability to care
for basic survival); increased risk behaviour (substance abuse, prostitution,
delinquency)
Spiritual Health: inability to give meaning (e.g. pre-occupation: why did it happen
to us?); decreased spirituality; religious fundamentalism; belief in being cursed or
punished by God; loss/neglect of rituals; intrusions of the dead (anxiety, dreams);
spirit possession (disorderly behaviour, inconsistent and unusual speech, somatic
symptoms); neglect of spiritual places; cynicism
Extras: Local idioms of expression of (violence related) emotional distress;
Local mechanisms to express distress;
Knowledge/beliefs on psychosocial consequences of violence (in terms
of functionality)
Project proposal related: beneficiary perspective (on assessment outcomes,
problem tree analysis, ways to intervene, expected outcome (in terms of
functionality), how to measure improvement), practical issues (e.g. possible
partners, national staff, geographical area)

Resilience indicators

Resource availability
Quantitative
Existence of laws and justice
mechanisms

See Physical, Mental, Social health in


early indicators: continue the unfinished
elements of the general needs assessment.
Spiritual
Religious or spiritual belief
Beliefs about the event
Rituals
Properly buried people
Places of contemplation and worship

Qualitative
Reports
FGDs
Key informant interview (clients,
leaders)
Listening
Structured observation
Diaries
Social mapping
Hierarchy mapping
Village drawing
Dictionary
Workshop (results, problem tree
analysis, intervention, expected
outcomes)

Religious institutions
(formal/informal)
Places of worship
Possibility and frequency of healing
rituals (e.g. memorials, burials)

Qualitative
Literature
FGD
Key informant interview
Listening,
Observing

Moral
Ability to forgive, have compassion
Justice system
Acknowledgment of and adherence to
Law
ethical rules/regulations
(In)formal rules on marriage,
Sense of contribution to a greater goal
heritage etc.
Drive to survive to serve a higher purpose
Overall conclusion about response intensity & possibilities for intervention
High Response Intensity: implement psychosocial project or component
High indicators of psychosocial problems, low signs of resilience and poorly developed resources
Normal level of psychosocial problems, low signs of resilience and poorly developed resources
Marginalised or other affected groups
Possibilities for intervention
Psychosocial component added to other programme activities or to a full community-based programme
Intervention is supported by staff
Realistic plan

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PROJECT PLANNING

J.1

Definitions
Humanitarian aid has traditionally consisted of providing life-saving assistance to populations
in danger during acute emergencies such as violent conflicts, natural disasters, and epidemics.
This type of assistance is considered distinct from development assistance, which focuses on
socio-economic rehabilitation in relatively secure areas.Today, NGOs find themselves working in
contexts that do not conform to either description, but lie somewhere in the middle of the
emergency development continuum. Often these situations are defined as chronic emergencies
because health and security environments are under constant threat. In such situations, neither
a pure emergency nor a pure development assistance approach is appropriate. Projects in
chronic crises must combine objectives, activities and strategies from both models of assistance
to ensure effectiveness.
The critical question for programme managers is, then: which operational strategy will best meet
the needs of the population? This question occupies many health professionals working in
contexts of chronic crisis.
In this chapter a rather strict separation between three forms of assistance (emergency, chronic,
development) is used as a model to explain what psychosocial projects should look like in the
various contexts.160
Three types of indicators are generally used to describe the success of a project.
Outcome indicators: related to Project Purpose
Output indicators: related to Specific Objectives
Process indicators: related to Activities
Process indicators assume a positive correlation between the activities and the specific objective.
The assumptions are mentioned in the logical framework. Outcome and output indicators prove
(instead of assume) the relationship between the activities and project purpose or specific
objective.161 Ideally, all psychosocial projects strive to define outcome indicators to provide a
basis from which to measure the effectiveness of their intervention. Realistically, most projects
define output indicators.
The areas of conflict or high instability in which MSF intervenes hardly ever allows for the
definition of impact indicators (related to the overall programme purpose).

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J.2

Mental health and psychosocial care in acute emergenciesxxiii

J.2.1

Project purpose
The project purpose is to support individual human physical survival by delivering care to
preserve lives and provide basic subsistence.

J.2.2

Specific objectives
The use of standard specific objectives and indicators (see table 32) is justifiable for an
emergency context where actions are limited by time and security. Within mental health or
psychosocial services direct treatment and care for mentally affected beneficiaries is the highest
priority in emergencies. When possible these activities should be provided along with
psychosocial care activities.
Mental health projects may also enhance the efficacy of other life saving services in the
Outpatient Department (OPD). A large flow of shocked, distressed, anxious and somatising
OPD patients can, for example, be referred to the mental health services. Outreach services are
useful to enhance the identification of vulnerable people (physical and mental). Psychosocial
education should be used to stimulate the self-help mechanisms of individuals or small groups.
The preservation of human dignity and assurance of protection are important. In emergency
medical assistance, ensuring dignity and security is an ethical imperative.

J.2.3

Indicators
The identification of reliable outcome and output indicators is not possible in emergency
settings due to the fast changing situations. Process indicators related to activities are often the
most valid indicators of programme effectiveness in emergencies.They show how activities are
saving lives and improving human dignity. Examples of useful process indicators include:
Number of people identified through outreach and number treated: These process indicators
assume that in emergencies, early identification and treatment of vulnerable people (both
physically and mentally affected) results in the improved likelihood of survival. Indicators of
enhanced self-help and self-organisation of clients are often described in terms such as all
clients are receiving support from their social networks who have received psycho-education.
Number of people referred: Psychosocial and mental health interventions improve the physical
survival of clients by affecting the output of other medical programme interventions. For
instance, in a nutritional crisis recovery from therapeutic feeding is enhanced through
psychiatric care for depression, and psychosocial support for clients and caregivers through
improved mother/child interaction. In basic health care institutions mental health services
reduce the strain on medical staff services by dealing with somatisation complaints or signs of
emotional stress. Encouraging survivors of violence to share their emotions, listening to their
stories and promoting self-care through small group education sessions, can increase the
efficacy of basic health care services. It also contributes to the human dignity of the
emergency medical services.

xxiii The format used for describing project planning in this chapter has been described before by Damme,W. van, Lerberghe,W. van & M. Boelaert, (2002).
Basic health care versus emergency medical assistance: a conceptual framework. Health Policy and Planning, 17 (1), 49 - 60.

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Protection and safety: Providing a safe place for beneficiaries to seek treatment directly affects
survival. General indicators are monitoring human rights abuses and advocacy actions.
However, specific indicators related to increased safety of women, children, severely (mentally)
ill, elderly are defined during the emergency.
Number of clients counselled:The respectful and humane treatment of clients, by paying
attention to their emotional suffering, improves the sense of human dignity.
J.2.4

Target group
As part of the emergency medical package, mental health services should focus on the most
vulnerable, including: psychiatric clients, suicidal, acutely shocked or traumatised, mentally disabled,
withdrawn people, and other identified vulnerable groups such as children, victims of sexual
violence and the elderly.

J.2.5

Time perspective
Emergency mental health projects range in length of implementation from days to several
weeks, and up to a maximum of 3 months.

J.2.6

Activities of care
Once the target population has been defined, and clinical and outreach services with
appropriate referrals have been established, several activities of care are in place:
Primary support that focuses on stabilizing the client through drugs, crisis counselling, and that
ensures clients have an (informed) social network to support them, for details see Chapter E
and Chapter F.
Psychosocial counselling that allows for expression and ventilation of emotions, promotes selfcontrol and provides advice.
Outreach services that identify vulnerable beneficiaries with physical and mental health problems.
Education and cooperation with existing social networks.
Mental health services that contribute to the protection and safety of beneficiaries by
monitoring human rights abuses and speaking out about them (see Chapter H for guidelines
on Advocacy).

J.2.7

Structure of services
Psychosocial services must be integrated into an outpatient department. Access can be
maximized through outreach workers who identify mentally and physically vulnerable cases at an
early stage. A referral system between physical and mental health services should be
encouraged. Sometimes an information and educational facility is identified to further reduce
strain on the medical and mental health services.
In contexts of limited accessibility mobile services are an option. In these cases, mental health
and, secondarily, psychosocial assistance focus only on acute cases.
All services are executed under the clinical supervision of a certified mental health worker.

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J.2.8

Human resources
Expatriate psychosocial worker(s) with a team of (inter) national caregivers (counsellors and
outreach) are responsible for providing mental health and psychosocial care services.Though the
involvement of local professionals is preferred, expatriate caregivers such as psychiatrists,
(clinical) psychologists, social workers, teachers can participate in the provision of care.
A basic unit of two expatriates (preferably one psychiatrist), 5 trained national counsellors and 8
outreach workers can effectively cover curative and preventive first-line activities for
approximately 10,000-15,000 people. If possible, staff should be recruited among beneficiaries
and should work on short-term contracts.
When psychosocial services are implemented through mobile teams, staff is often limited to one
or two (expatriate, national) staff.

J.2.9

Training
Training of (expatriate or national) medical and outreach staff is limited and focused on the
execution of standardised tasks.

J.2.10 Strategic aspects


To increase the efficacy of overall medical services, mental health support should be
implemented within existing medical activities. Additional or parallel psychosocial activities should
not be excluded as an option, but need further justification before implementation.
Projects specifically address needs resulting from a crisis situation; therefore sustainability is of no
priority. Cooperation with local health authorities is important, but often of limited value in
acute emergencies.

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Tbl. 32 Summary of essential features of a mental health and psychosocial intervention in an acute emergency
Mental health and psychosocial care in acute emergencies
Project purpose

Reduced mortality due to psychiatric and psychological problems

Specific objectives

Psychiatric and psychological treatment is available to the population


Reduced burden from physical health services through the provision of care for
beneficiaries with acute psychiatric or psychosocial complaints
Human dignity is respected in the intervention
Protection issues are addressed

Indicators

Output indicators:
Cross-culturally valid indicators cannot be developed within short time periods and rapidly
changing contexts
Process indicators:xxiv
Number of stress related complaints and disorders treated in OPD
Number of psychosocial & psychiatric clients seen and supported.
Appropriate cross referrals made by physical & mental health and outreach services
All clients receive respectful, humane treatment (e.g. attention to emotional suffering of
the client)
All significant members of social networks received psycho-education
All clients are supported by informed social networks
Monitoring of human rights abuses (including sexual violence)
Advocacy action on safety and security issues of beneficiaries

Target population

The most vulnerable: psychiatric clients, suicidal, acutely shocked/traumatised, mentally


disabled, withdrawn people, and other identified vulnerable groups (e.g. the elderly).

Time perspective

Short term (max 3 months)

Activities

Drug treatment, crisis counselling, outreach


Psychosocial counselling including: active listening, allowing for expression of emotions,
provision of advice, stimulation of self-control
Improvement of self-help mechanisms and self organisation through education and
involvement of social networks of the client
Integrated outreach services identify vulnerable (physical & mental) individuals
Monitoring of, and advocacy about, protection and safety issues

Structure of
Services

OPD, outreach, referral, information centre


Mobile services in areas with limited access
Clinical supervision of mental health expatriate

Human Resources

2 expatriates (preferably 1 psychiatrist), 5 national counsellors, 8 outreach workers for


10,000-15,000 people
Mobile team: one or two (expatriate, national) mental health staff

Training

Limited, focused on standardised tasks (medical and outreach staff)

Strategy

Mental health integrated into overall services


Additional psychosocial services need further justification
Sustainability low
Cooperation with authorities of limited value

xxiv If process-indicators (related to activities) are used the assumptions need to be mentioned.The relationship between the process indicator and
the specific objective has to be proven in other contexts (e.g. treatment of psychiatric clients in crisis situations reduces morbidity and mortality).

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J.3

Psychosocial care in chronic crises

J.3.1

Project purpose
The purpose of a psychosocial project in a chronic crisis is to improve the daily functioning of
the most vulnerable.To help people cope with such a situation, we need too look beyond basic
physical survival and protection to build social and emotional endurance.

J.3.2

Specific objectives
Specific objectives for a psychosocial project in chronic crises cannot be standardized for
two reasons:
Firstly, the nature of a chronic crisis is that of uncertainty. Both deterioration and amelioration
of the social and security context are possible. Inevitably, a mixture of acute emergency and
post-crisis specific objectives are necessary to ensure a built-in flexibility.
Secondly, projects in chronic crises need to address the specific, locally defined consequences
of violence.Therefore, a context and culture specific problem tree is needed to further define
the specific objectives.
Often specific objectives include the improvement of knowledge, and skills for self-management
of psychosocial problems and improved functioning of beneficiaries.

J.3.3

Indicators
In principle, psychosocial projects in chronic crises need to design cross-culturally validated
outcome or output indicators. Whether or not it is possible to do so depends on the context,
the willingness of the team, and the amount of time and resources available to the project.
Locally developed outcome or output indicators should be developed with the assistance of the
local population.Through Focus Group Discussions (FGD), and key informant interviews, the
beneficiary perspective of the psychosocial problems is researched. Consideration should be
given to how locals interpret the improvement of their physical, mental, social, spiritual and
moral health, and to how it can be measured. It is suggested to describe the locally defined
outcome, or output indicators for both the psycho and the socio-component in terms of
functionalityxxv and coping, for instance the improvement of social contacts, ancestors are resting
in peace, decreased worrying, improved physical activities, improved ability for self-care,
improved family relationships, and increased number of daily activities etc.
It may not always be possible to develop locally defined outcome, or output indicators e.g. in
situations with security constraints, lack of human resources, insufficient educational level of the
staff, inexperienced expatriate or project team. It must be noted, however, that the use of
process indicators hinders a proper effect evaluation of the specific objective or project purpose.
In these circumstances process indicators can be used to describe the effectiveness of the
programme. Assumptions have to be described in the logical framework. A combination of
qualitative and quantitative indicators is highly recommended:

xxv Functionality is a dynamic term that refers to both physical survival, psychological and social performance. It is defined in close connection to other
parts of the local society, the context and the prevalent culture. Contrary to indicators in post-crisis programmes, functionality is described in
terms of (long-term) survival, coping and not in terms of well-being.

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Quantitative indicators of success describe: increased number of people seen in the


counselling services, reduction of complaints or problems (psycho-component), increased
number of community activities (education or other), increased number of people attending,
increased number of people supported through community outreach services (sociocomponent) and monitoring of human rights abuses or protection issues.
Qualitative indicators of success describe: quality services provided, improved restoration of
human dignity, perceived improvement of complaints, beneficiary satisfaction (psychocomponent), proximity to target population (e.g. presence in the community), the
connectedness and quality of the community network (socio-component) and a specific
indicator for advocacy action.
J.3.4

Target group
The target population is those individuals who suffer from the psychosocial consequences of
violence.The psychological or emotional suffering can either be caused by a direct impact from
traumatic experiences or indirectly through lack of protective mechanisms (see B.4 Resilience).

J.3.5

Time perspective
Project implementation can vary in length of time from six months to up to three years.

J.3.6

Activities of care
The types of activities of care offered by a psychosocial programme depend on the level of
intervention, Figure 7 and Chapter G.3.
Given the chronicity of the situation, endurance is promoted through increased functioning of
the individual.Thus victims coping mechanisms and resilience resources (physical, social, spiritual
and moral) mechanisms are reinforced.
On an individual level (as described in detail in Chapter E), coping is supported through crisis
and supportive counselling.This is the psycho -component).
To further reinforce resilience mechanisms for the individual, community resources can also be
included in the intervention (the socio -component). Chapter F describes how, for instance,
psycho-education can be included in general health education, a referral network of NGOs
can be organized, local organisations and traditional mechanisms of care and coping can be
mobilised. Community leaders and other influential members of the community such as
school teachers, medical professionals are encouraged to re-assume their traditional,
previously held, roles in society. Distraction activities to improve the atmosphere may be
included in the activities.
If protection and human rights issues emerge they need to be monitored, and if
possible addressed.

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95

J.3.7

Structure of services
Psychosocial projects in chronic crises have to deal with a dilemma about whether to
integrate mental health into existing services or establish a separate vertical system. In many
non-Western countries psychosocial, or even mental health services, are often non-existent or
underdeveloped. Chances of building a sustainable service are low. Despite the low probability
of sustainability MSF chooses to realize psychosocial and mental health interventions. For this
reason sustainability of the services has low priority in programme implementation.The choice
must not exclude close collaboration with the community (local representatives, NGOs), and
with existing health and social services.
MSF has chosen to address psychosocial and mental health needs when there is a marked
prevalence of mental or psychosocial dysfunction in a population. Systems building and
sustainability are not a priority for MSF.The first priority is to establish a proximity to the
beneficiaries that enables us to address their needs through the provision of quality care. In
extreme circumstances this may result in MSF initiating a separate, temporary programme that is
parallel to existing national health services. Most psychosocial projects in chronic crises are
closely connected to the existing health care system (e.g. through training or referral).
Experience shows that in reality the services are seldom continued by the local health system
after the crisis.
Psychosocial support in chronic crises can take on a variety of forms:
Basic support as provided in each medical relationship;
Psychosocial referral service (local NGO, national or expatriate specialist);
Psychosocial community-based programme (see Chapter G.3, Figure 7).
Psychosocial care should be implemented in an OPD. Psychosocial care services must be
executed under the clinical supervision of a certified mental health expatriate. Where possible, a
local counterpart (mental health professional) can also participate in the clinical supervision
process.
Connectedness to the community (the social component) is very important. To stimulate selfhelp of the individual and the community, a local referral support network outside the health
system needs to be used.
The implementation of psycho-educational awareness activities in the community is only
possible when clinical back up is available.

J.3.8

Human resources
A team of 1 expatriate, 5-10 trained national counsellors, and 10 community workers can
effectively assist a population of 15,000-20,000 people. Local staff should preferably be recruited
from the existing health system. However, in reality the lack of professional health workers
forces us to recruit among beneficiaries and host population.
If the psychosocial activity only involves a psychosocial referral component (see G.3, Figure 7)
then usually one or two (expatriate, national) mental health staff is sufficient.

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J.3.9

Training
Training improves health workers ability to support beneficiaries. It is not the aim to create
certified mental health specialists or expert community workers.
Medical staff may need training about how to provide basic psychosocial support in medical
settings, and how to identify and refer people suffering from psychological problems.
Community workers and counsellors should be trained about community mobilisation, and
(mass) psycho-education.They should also receive extra, ongoing training on counselling skills.

J.3.10 Strategic aspects


To increase effectiveness of the services, psychosocial support activities should preferably be
part of a basic health care project or a component of a specialized programme like T.B.,
HIV/AIDS, or nutrition.Vertical psychosocial project activities should not be discarded as an
option, but need justification.
Psychosocial projects combine psychoand socio activities. Programmes that only focus on
psychoor socio components are less effective.The balance between both activities depends on
the local situation and culture.
Having an exit strategy is important, but should not influence the decision to start a project.
The psychosocial project should maintain close communication with the population it is serving.
This promotes coping, facilitates self-help and other resilience mechanisms. Daily presence of
expatriates in the community, strong links to NGOs, community systems and significant people
that can support the social, spiritual and moral health issues are vital.

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97

Tbl. 32 Summary of essential features of a psychosocial intervention in chronic crises


Psychosocial care in chronic crises
Project purpose

Enhanced functionality and improved coping of the most vulnerable

Specific objectives

Defined locally depending on assessment and problem-tree analysis


(E.g. to improve clients knowledge and skills about self-management of psychosocial
problems; to improve clients daily functioning)

Indicators

Output indicators:
Defined by the local population in terms of individual and group improvement in daily
functioning (e.g. improvement of social contacts, ancestors are resting in peace, decreased
worrying, improved physical activity, improved capacity for self-care, improved family
relationships, increased number of daily activities)
Process indicators:xxvi
Quantitative: increased appropriate cross referral (OPD component), increased number of
people seen in the counselling services, reduction of complaints/problems (psychocomponent), increased number of community activities (education or other), increased
number of people attending and number of people supported through community
outreach services (socio-component)
Qualitative: quality service, beneficiary satisfaction, perceived improvement of complaints,
beneficiary satisfaction (psycho-component), proximity to target population, connectedness
& quality of community network (socio-component)
Advocacy: human rights abuses or protection incidents, advocacy actions

Target population

Individuals suffering from psychosocial consequences of violence

Time perspective

6 months 3 years

Activities

Psycho-component: supportive & crisis counselling


Socio-component: health education, community mobilisation, connection to other NGOs,
promotion of self-help (e.g. traditional care & support mechanisms), stimulation of
distraction activities, restoration of community repair-mechanisms.
Monitoring of human rights and protection issues

Structure of
Services

Human Resources

1 expatriate, 5-10 trained national counsellors, 10 community workers cover population of


15,000-20,000 beneficiaries

Training

Training is a tool not a project goal!


Medical staff: training about provision of basic psychosocial support in medical settings (e.g.
communication skills, crisis interventions), identification and referral of people suffering from
psychological problems
Community workers: training about community mobilisation, and (mass) psycho-education
Counsellors: training about community mobilisation, and (mass) psycho-education, and
extra, ongoing training on counselling skills.

Strategy

Dilemma of short term effectiveness or long term sustainability


Organisation of services depends on needs and staff availability (G.3, Figure 7)
Services in outpatient setting and closely connected to existing health systems
Referral network to the formal health system and to community organisations.
Implementation of psycho-educational activities in the community only when there is clinical
back-up
Clinical supervision of MSF mental health expatriate preferably with a local counterpart

Part of other medical intervention (e.g. basic health care,TB, nutrition, HIV/AIDS)
Strong community connection and involvement to increase efficacy
Balance psychoand socio components
Exit strategy and sustainability are secondary priorities (though attention must given)

xxvi If process-indicators (related to activities) are used, the assumptions need to be mentioned.

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J.4

Psychosocial care in Post-Crisis or Rehabilitation Contexts


MSF rarely works in post-crisis or rehabilitation settings. Nevertheless, this section is included for
three reasons. Firstly, certain components of psychosocial care programming for post-crisis
projects are also used in projects in chronic crises. Secondly, HIV/AIDS interventions in which
psychosocial activities play an important role do not necessarily follow the emergencydevelopment continuum. Lastly, a typical issue that is addressed in rehabilitation projects: the destigmatisation and sometimes de-criminalisation of mental health, is often very relevant for
mental health and psychosocial projects in chronic crisis.

J.4.1

Project purpose
Psychosocial care in most post-crisis settings aims to improve all peoples mental health (in the
broadest definition) instead of being limited to violence related complaints. Project purposes
encompass care, cure, protection and health system autonomy.

J.4.2

Specific objectives
Specific objectives for the project should be identified and developed by the beneficiaries or
their representatives.The specific objectives often include the specific aspects of the mental
health problems that need to be improved, support for capacity building, service design
(sometimes implementation) and technical guidance etc.

J.4.3

Indicators
Outcome and output indicators of success should be defined in terms of quality, efficiency,
effectiveness, participation, protection, autonomy and exit strategy.

J.4.4

Target group
The target group is all those in need of psychosocial support.

J.4.5

Time perspective
The intervention is aimed at sustainability and requires a long-term perspective.

J.4.6

Activities of care
Sometimes technical support is provided and capacity building facilitated in post-crisis situations.
However, the emergency-focused knowledge and limited time commitment of emergency
NGOs nearly always excludes them from these types of programmes.
Psychosocial care activities in post-crisis situations should integrate curative and preventive care
with health promotion.The provision of health care should be done in a holistic manner that
takes into account the physical, psychological and social dimensions of health and wellbeing.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

99

Activities of psychosocial and mental health services in basic health care include: symptom
relief, counselling, psychotherapy, and drug therapy; assistance for coping with the inevitable;
and preventing further deterioration through continuous health education.
Quality aspects of the relationship between beneficiaries and health care provider such as:
active beneficiary participation, supportive relationships, trust in the caregiver, maintenance of
beneficiarys autonomy and family ties, shared decision-making etc, are important aspects of the
activities.
Special activities related to destigmatisation or decriminalisation can be implemented when
relevant. In the case of human rights or protection issues of the mentally ill, activities must
include active monitoring of clients.
J.4.7

Structure of services
To increase the efficacy of prevention, decrease suffering (by early identification) and increase
self-help (by psycho-education), psychosocial care services need to be community-based.
Psycho-education is done through the established community health worker systems.
A basic organisation unit can cover approximately 10,000-15,000 people. Referrals should not
be limited to the health and community system, but include all structured government and
private initiatives.
A national mental health specialist should be responsible for clinically supervising services.

J.4.8

Human resources
Expatriates should provide hands-off advice and not be involved in any client relationship.They
should function only as specialists who give training and technical advice about clinical and
organisational issues. National professionals execute the psychosocial/mental health services, and
have long-term employment contracts.

J.4.9

Training
Training staff about clinical and organizational issues is one of the major activities.Training should
be in-depth to develop knowledge and skills that are important for the long term. Human and
client-rights training should be considered as an important subject for training.

J.4.10 Strategic aspects


In post-crisis situations, psychosocial and mental health support should exist within an effective,
and integrated basic health care system. It has to balance, both collectively and individually, the
professionally defined needs and the demands expressed by the client.
Psychosocial services should be developed in harmony with other aspects of culture and society
such as local belief systems, political, economic and religious systems.
If de-stigmatisation, de-criminalisation, clients rights and inpatient care are defined as a specific
project purpose the intervention is focused on catalyzing change. Collaboration with local
administrators and political authorities is necessary to achieve commitment and to promote
autonomy.The programme should be implemented through the Ministry of Health who acts as

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

the major implementing partner.The Ministry of Health should make all decisions regarding
policy, resource allocation (by the overall budget) and priorities in setting norms for both change
and expected behaviour or attitude. Sustainability of services is very important and often the
exit strategy is a planned objective.The role of foreign support should be one of technical
assistance. Substitution can only be justified as an interim measure and on a temporary basis.
Tbl. 34 Summary of essential features of a psychosocial intervention in Post-Crisis/Rehabilitation
Psychosocial care in Post-Crisis/Rehabilitation
Project purpose

To respond to all peoples mental health needs and demands

Specific objectives

Locally defined by beneficiaries (often in terms of capacity & service building).


Extra specific objectives regarding destigmatisation, decriminalisation or clients rights can be
included

Indicators

Outcome and output indicators should be defined in terms of quality, efficiency, effectiveness,
participation, autonomy and exit strategys

Target population

All those in need

Time perspective

Long-term

Activities

Curative care
Psychosocial assistance
Preventive actions
Promotion of health as physical, social and mental well being
Destigmatisation
Lobbying, advocacy (optional)
Monitoring rights (optional)

Structure of
Services

Community-based
Budget from health system
Basic unit serves 10,000-15,000 people
Clinical supervision by national mental health specialist

Human Resources

1 expatriate who acts as advisor

Training

In-depth training on clinical and organisational issues

Strategy

Integrated services within the national health system


Autonomy, participation and collaboration
Partnership with Ministry of Health
Harmony with other social, spiritual and moral aspects of the society and culture
Catalyst for change (optional)

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101

TRAINING
Training in a psychosocial project is an important tool but never a project goal in itself.Training
should be practical and focused on helping clients with psychosocial problems. Except for the
psychosocial skill training of the medical staff, it is never a stand-alone activity.There are serious
ethical problems around doing harm where national staff are exposed to knowledge and skills
without proper clinical back up for community workers or clinical supervision for counsellors.
Therefore, if community workers are trained, proper referral mechanisms (to trained medical
staff, clinically supervised local counsellors, or a mental health specialist) have to be ensured.
Training counsellors without daily clinical supervision of a mental health specialist (local or
expatriate) is potentially harmful for beneficiaries and for the staff themselves.

K.1

Trainers attitude and methodology


Being a trainer requires a modest, open and curious attitude. Inappropriate ways for a trainer to
manage anxiety and uncertainty, such as creating an expert status and lecturing, can hinder the
process of exploration and dialogue with participants. An interactive process between the
trainer and participants is vital to bridge cultural differences.The trainer should be responsible
for facilitating this process. Cross-cultural training is based on three principles:
I.

(Re)discovery of knowledge already available among participants: Instead of arriving with a


fixed curriculum about knowledge, attitude and skills required for effective counselling,
existing knowledge among participants is taken as the point of departure.The trainers role
is to facilitate the discovery process and to encourage participants to share their knowledge,
skills and self-help mechanisms while using local language and concepts.

II. Attention to personal needs of participants: Almost all participants in the training will have
their own personal, traumatic experiences, for which they need some support.The training
is not only educational for participants, but also therapeutic. Education and therapy are
nicely combined during training through practice activities. Counselling techniques learned in
class can, for example, be put into practice by having participants counsel each other.
Participants thereby benefit doubly by learning about counselling and having their personal
suffering alleviated.The trainer must ensure a safe environment that protects participants
from re-traumatisation. When necessary the trainer can conduct individual consultations.
III. Sharing of Western knowledge and translation to local culture: Western insights can be
shared and, when accepted, translated for the local culture. It should be taken into account
that the participants need a concise, short-term and practice-oriented training without
professional jargon that is in line with their level of formal education.
K.2

Training about psychosocial support in medical settings


Training is necessary for all national and expatriate medical staff working in projects that have a
mental health or psychosocial component.The purpose of staff training is to improve knowledge
about the psychological consequences of violence, (local) coping mechanisms, case identification,
and referral options. Special attention should be given to the attitude and skills required to give
psychosocial and emotional support in a medical setting, such as the ability to listen, convey
compassion, deal with emotions, provide or mobilise company, encourage (not force) social

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contact, intervene in crises and protect from further harm. The two or three days of training do
not aim to turn the medical staff into counsellors. In emergency situations the duration of the
training can be reduced.
K.3

Training about psychosocial support in the community


MSF presence in the community is vital for psychosocial projects.The social package as discussed
in the general objectives (see section D.3.2 on Social package), materialises through community
work. It is important to create an environment that enables traumatised survivors to reconnect
with their environment. Community presence also ensures improved proximity and
understanding of the beneficiaries needs.
Community work training should be given to both community workers and counsellors.
Counsellors should be exposed to this training to ensure that they see their job as a
combination of psychological and social tasks.
Ideally, training is given by members of the local population. However, in most cases the mental
health expatriate has an instrumental role. Initial training lasts two weeks. Formal and on the job
training should continue regularly during the project.

K.3.1 Knowledge
Information about the programme and its services should be provided during its course. Specific
topics like stress, mood problems and other major issues such as suicide or substance abuse in
the community, as identified in the assessment, should be discussed. Local self-help mechanisms
such as peer support are explored and if relevant extended with other techniques. Issues like
confidentiality, advocacy and monitoring should also be addressed.
K.3.2 Skills and attitude
Practical issues like community mobilisation, planning and making health topic presentations and
organising distraction events should receive attention. Special attention should be given to the
design of education material such as leaflets and posters.
Working in the community confronts the workers with immediate problems that need
intervention.Therefore, support skills like active listening, compassionate attitude, knowledge of
how to deal with emotions, provide or mobilise social networks, crisis intervention, protect from
further harm, case identification and referral should be part of the training package.
K.3.3 Community exposure
Some exposure to problems in the community should be included in the training. Participants
can learn to compose a social map of (in)formal community resources, and to introduce
themselves and the programme to the community and its leaders.They can practice data
collection methods such as in-depth interviews and focus group discussions.

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K.4

Training about counselling


Training for counsellors is mainly technical in nature, providing supportive, emotional counselling
skills. A cross-cultural training methodology for counsellors, based on experiences in various
parts of the world, has been developed.162 To ensure continuity in the development of
counsellors, external mental health professionals should provide formal training in close
cooperation with the mental health expatriate.
As with training programmes for community health workers (see K.1 Trainers attitude and
methodology), the curriculum for counsellor training cannot be designed beforehand.The initial
training must cover the following topics: introduction and evaluation of the training, the work of
the counsellor, communication and interviewing, problems of the people in counselling, how to
help, personal growth, physical exercises and counselling as profession (e.g. confidentiality,
advocacy and monitoring).
Initial training should last two weeks.Training should continue with on-the-job training and
clinical supervision. Formal follow-up training should be conducted at least once a year.

Tbl. 35 Overview of psychosocial training curricula


Target Group

Proposed General Curriculum

Medical staff
(expatriate, national)
(2 or 3 days with follow-up,
given by expatriates)

Knowledge
Confidentiality
Psychological consequences of violence
How to explain (psycho-education)
What others should do about it (local coping mechanisms)
How to help yourself (self-help techniques)
Case identification, and
Referral options
Attitude and skills
Listening & communication
Dealing with emotions
Crisis intervention

Community workers
and counsellors
(2 weeks, given by
expatriates)

Knowledge
Programme and its services
Specific topics: stress, mood problems and other major issues
Self-help mechanisms
Confidentiality, advocacy and monitoring
Skills & Attitudes
Programme and self introduction
Listening & communication
Community mobilisation, planning & making health topic presentations or distraction events
Design of education material
Crisis intervention, relaxation, dealing with aggression and conflicts and case identification
Community exposure
Community problems, social map of community resources,
Self and programme introduction

Counsellors training
(2 weeks, given by external
trainer volunteers)

104

Programme and self introduction


The work of a counsellor
Listening & communication
Interviewing
Confidentiality, advocacy and monitoring
Introduction and evaluation of the training
Problems of the clients counselling
How to help
Personal growth
Physical exercises

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

K.5

Clinical supervision
Clinical supervision is a training method whereby counsellors examine a client case that causes
technical difficulties or triggers strong personal emotions. Clinical supervision is a contracted
activity; it is a shared reflection between the expatriate as clinical supervisor and the counsellor,
focusing on the counsellors client case.The goal is to give the counsellor guidance in the
delivery of cognitive and emotional care to his clients.163
Clinical supervision can be done individually or in groups. If regarded as an advanced way of
learning it has several purposes:
To encourage the learning process of counsellors through critical dialogue and reflection on
client cases.
To contribute to self-knowledge and self-understanding (personal growth) of the counsellors,
by encouraging them to reflect on their own feelings, thoughts and behaviour.
To explore personal problems and find new ways of dealing with them.
The work of the counsellors is sometimes very demanding..They need to give support to
traumatised clients while often being exposed to traumatic experiences themselves. Providing
the opportunity for clinical supervision can therefore contribute to the mental hygiene and
burnout management of the counselling staff.
For the expatriate mental health specialist working in non-Western settings clinical supervision
provides a good opportunity to stay tuned into the psychosocial problems and needs of
the community.

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MONITORING AND EVALUATION

L.1

Principles
It is difficult to measure and monitor the effectiveness of psychosocial programmes164 in
emergencies due to several factors:
Conventional monitoring and evaluation criteria are not applicable or valid in changing,
unpredictable and unstable contexts. Field reality challenges conventional evaluation criteria
such as determinants of effectiveness. Furthermore, documentation and systematic
measurement of outputs is often not possible in emergencies.
Epidemiological evaluation models advocated by Western psychiatry are insufficient to prove
the effectiveness of humanitarian actions.165 For example, evidence-based psychology and
medicine use effectiveness or impact as justification for psychosocial interventions, but
epidemiological data does not tell us anything about the fundamental motives for
humanitarianism: compassion, empathy and a sense of justice. Furthermore, most evidence is
based on Western situations and for higher technological interventions.
The cultural differences in the perception of trauma, expression of suffering, and the
mechanisms for coping makes it difficult to generalise from one context to the other.166
Culture-specific models and instruments to evaluate programme outputs improved resilience
require extensive time and resources (i.e. a long-term investment on behalf of MSF).
As a consequence, most projects depend on process indicators and qualitative research
outcomes to determine the effectiveness of their activities.
Since 1990, MSF and other organisations have progressively improved their evaluation models
and criteria for psychosocial interventions through evidence-based research,167 and evaluating
techniques.168

L.2

Acute emergencies
Acute emergency contexts change quickly.There is insufficient time to determine cross-culturally
validated outcome (impact) or output indicators. Process indicators (measuring activities) are
therefore used for programme planning and monitoring (see J.3). The relationship between
acute mental health interventions and positive treatment outcome is well established in other
settings. For instance, administering a psychotic client with anti-psychotic drugs is proven to be
effective in many settings.

L.2.1 Outpatient Departments (OPD)


General clinical monitoring in the health services should include the registration of psychiatric
disorders, and stress related complaints or disorders. (Cross-) referrals should be registered to
monitor cooperation between the physical and mental health/psychosocial services.
L.2.2 Mental health and psychosocial services
Mental health and psychosocial services should monitor basic client data like demographics,
information about the type of problem, for instance symptomology, and treatment such as drugs
and counselling provided.The appropriateness of psychosocial support given by the counsellors

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is monitored through clinical supervision and case discussions. General issues like humane
treatment, decent waiting areas, a sense of privacy, compassionate attitudes of health staff,
understanding of emotional suffering and confidentiality are observable process indicators in an
acute emergency.
L.2.3 Outreach
The main tasks of outreach services are to identify vulnerable individuals and refer them to
health or other services accordingly. In addition, outreach activities should provide information,
and basic assistance to people.
Tbl. 36 Overview of a monitoring system in acute emergency psychosocial care
Process Indicators

Source of Verification

Monitoring/Evaluation Tools

Number of stress-related
complaints and disorders in
OPD service

OPD medical monitoring

Health monitoring file (health complaints/disorders,


psychiatric/stress related complaints/disorders, referrals
& returns)

Number of psychosocial &


psychiatric clients seen

Psychosocial monitoringxxvii

Client files (demographic data, symptoms, problems,


presence of social support, type of treatment, improved
functioning, referral & returns)

Appropriate cross referrals


by physical, mental health,
and outreach services

OPD medical monitoring


Psychosocial monitoring

See health monitoring file


See client file
Community outreach file (areas covered, types of cases
identified (physical, mental health & psychosocial
complaints), intervention (information, education, crisis
intervention, mediation, referral, organized activities
(education, distraction etc.), number of people attending)

Adequate intervention

Observation
Interviews

Regular supervision
Case discussions

Respectful treatment of
the individual

L.3

E.g. humane treatment, attention to emotional suffering of the


client, decent waiting areas, a sense of privacy, compassionate
attention, understanding of emotional suffering, confidentiality

Chronic crises
Psychosocial projects in chronic crises combine emergency and development objectives,
activities and strategies. In principle, psychosocial projects in chronic crises need to develop
cultural-specific and locally defined outcome, or output indicators. Often, a standardised and
locally validated symptom or functioning checklist is not available.To create one, the local
population needs to be consulted and further research is required.This increases proximity and
allows for fine-tuning of the project to meet beneficiaries needs. A promising methodology is
described by Bolton.169

L.3.1 Output indicators


Validated quantitative output indicators should be defined during project assessments, and
modified during implementation of a programme as knowledge about the local community and

xxvii Psychosocial monitoring is part of the overall medical monitoring

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

107

context increases. Output indicators should be described both in qualitative and quantitative
terms. Output indicators should be described from a local individual and group perspective,
and include information about the following:
Local signs and symptoms of trauma related dysfunction and pathology
Local terms used to describe the improvement of psychosocial functioning or the reduction
of disability
Consequences of violence in terms of psychosocial functioning
Expected outcome of a psychosocial intervention
Examples of quantifiable positive outputs for traumatised people may include: reduction of
locally defined symptoms, ability to care for their family; increased number of meetings with
others; improved self-control over daily activities (e.g. self sufficiency in resources) and reduced
inter-relational conflict.These are just examples and need definition in local language. Surveys are
organised to measure knowledge improvement for instance on stress-related behaviour and
familiarity of psychosocial services as a result of social and educational activities.
The appreciation of services as qualitative output indicator is measured by means of
questionnaires.
L.3.2 Process indicators
Defining output indicators is time-consuming. Various reasons such as critical needs, lack of staff,
or insufficiently experienced staff, teams can stop the development of output indicators. Process
indicators are then used instead to describe the effectiveness of a programme. It must be
realised that process indicators only cover the activity level of the project. In other words the
decision to use process indicators limits future programme evaluation to the activities level.
Moreover, unlike in emergencies, the assumptions between the indicators and the effect on the
psychosocial condition of the client are less evident. For example, it is not certain whether
cognitive behavioural techniques that function in Western cultures have similar positive effects in
non-Western societies.
Process indicators are described both in qualitative and quantitative terms. Examples of
quantitative indicators are: number of stress related complaints or disorders, appropriate cross
referral to community and health services, number of people seen in counselling services and
the number of counselling sessions per counsellor. On the group level (socio-component),
indicators include a number of community activities (educational or otherwise), the number of
people attending, the number of people supported through community outreach services and
monitoring of human rights abuses or protection issues.
Qualitative indicators can further describe the extent to which activities affect the condition of
the client or community, and include: quality of services operationalised as sufficient client
contact time, file keeping, confidentiality, training and knowledge of counsellors, level of case
discussion etc.), improved restoration of human dignity, beneficiary satisfaction (psychocomponent), proximity to target population for instance presence in the community,
connectedness, quality of the community network like contacts with other NGOs, chiefs, leaders
and traditional healers (socio-component), and a specific indicator for advocacy action.

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Tbl. 37 Overview of a monitoring system for psychosocial care projects in chronic crises
Indicators
Output indicators:
Quantitative:
Psycho-component: If there are
no local culturally validated
symptoms of expression, then
local definitions of individual and
group improvement of
symptoms or functionality are
needed

Complaint reduction
Functionality improvement

Source of Verification

Monitoring/Evaluation Tools

FGD
Key informants
Workshops

What people expect from intervention in terms of


psychosocial functioning
How people define improvement of their psychosocial
functioning (or tasks)
How people define improvement of their psychosocial
condition
E.g. Consequences of violence in terms of psychosocial
functioning and disability from the beneficiarys perspective,
such as: ability to care for their family, increased number
of meetings with others, improved ability to self-support,
reduced inter-relational conflicts

Questionnaire

Pre/post measurement of severity of complaint and


daily life dysfunction
Symptom or function checklist

Socio-component: improved
Survey
knowledge about violence related
psychosocial problems, improved
knowledge about the services
Qualitative:
Service satisfaction
Process indicators:
Quantitative:
OPD component: number of
stress related complaints or
disorders, appropriate cross
referral
Psycho-component: number of
people seen in the counselling
services, number of counselling
session per counsellor

Exit interviewsxxviii
Drop-out analysisxxix

Satisfaction checklist

OPD Medical
Monitoring
Exit-interview

Health monitoring file (stress related


complaints/disorders, psychosocial referrals and returns)

Psychosocial monitoring
Exit-interview
Drop-out analysis

Client files (demographic data, symptoms, problems,


priority, self-help mechanisms, presence of social support,
desired outcome of treatment, type of treatment,
reduction of complaint or improvement of functionality,
referral & returns, drop-out rate)

Socio-component:
Psychosocial monitoring
number of educational
Monthly reports
community activities (education
or other), number of people
attending and number of people
supported through community
outreach services, community
networking, number of referrals
Qualitative:
beneficiary satisfaction, quality of
counselling (psycho-component),
proximity to target population,
connectedness & quality of
community network (sociocomponent)

Advocacy

Questionnaire

Community outreach file (areas covered, types of cases


identified (physical, psychosocial complaints), intervention
(information, education, crisis intervention, mediation),
referral (physical, mental, etc.), organised activities
(education, distraction etc.), number of people attending
Community networking: (frequency of contacts with
community significant people, frequency of contacts with
local organisations, number of referral to other organisations)

Key informant
FGD among
beneficiaries
Observations
Survey
Exit interviews
Drop-out analysis

Perception of beneficiaries (improvement of (individual,


community) functioning, reduction of complaints, problems
Quality (e.g. sufficient client contact time, file keeping,
confidentiality, training & knowledge of counsellors, level
of case discussion)
Knowledge and awareness of services
Perceived importance of project activities
Relationships with key people in the community

Advocacy strategy
Reports
Observations

Report, advocacy activities and outcomes


Witness reports
Health statistics

xxviii Exit interview: clients leaving the counselling session are interviewed on certain topics (e.g. satisfaction with services, improvement of complaints,
increased functioning etc.)
xxix Drop-out analysis: A random selected number of people of the group who did not follow-up on their appointments are interviewed about their
reasons for dropping-out, current level of symptoms, complaints, etc.

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HUMAN RESOURCES MANAGEMENT

M.1

Recruitment of expatriate and national staff


The two most important criteria for expatriate selection to consider during recruitment are:
Professional background such as psychiatrist, psychotherapist, clinical and counselling
psychologist, social worker and social psychiatric nurse;
Work experience preferably clinical and community-based;
Attitudes/expectations towards humanitarian work.
The project management is responsible for recruiting national staff (counsellors and community
health workers). Selection criteria such as age, gender distribution, professional background
should be developed locally. Staff selection should not only be limited to those with a
professional background. Other criteria are equally important, such as: attitude (e.g. the applicant
should be compassionate), interpersonal skills (e.g. good communication), interest in and
motivation for the work, previous counselling experience, training, and the ability to analyse, plan
and intervene when faced with difficult or complex cases.

Tbl. 38 Criteria for staff recruitment


Criteria

M.2

Expatriate

Professional background (e.g. psychiatrist, psychotherapist, clinical & counselling psychologist, social
worker, social psychiatric nurse)
Work experience (clinical, community-based)
Attitudes/expectations towards humanitarian work

National

Professional background
Attitudes and compassion
Interpersonal skills
Level of interest and motivation for the work
Previous counselling experience and training
Ability to analyse, plan and intervene when faced with difficult or complex cases (tested through the use
of three short case studies)

Job descriptions
The job descriptions of all psychosocial workers (mental health expatriate, counsellors and
community health workers) must contain an explicit statement about the obligation to respect
the confidentiality of the counselling relationship.
In the job description of expatriates or national staff it seems logical to divide tasks along the
lines of the psychoand the socio-components of the programme. However, this may result
in a distinct separation between the two activities. Clinical people should not feel responsible
only for the psycho-component and community people only for the socio-component.
Such separation can seriously reduce the success of the project.To avoid this problem it is
advised to combine clinical and community components in the job descriptions of the mental
health expatriate and the counsellors.

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M.3

Staff support
Members of national staff (including management, translators and drivers) are often traumatised
themselves. Additional daily confrontation with clients problems, traumatic stories, sadness and
loss are demanding and potentially draining.This is especially the case when faced with clients
who have little chance of significant improvement, for instance the terminally ill or AIDS clients.
Therefore, the risk of professional burnout is high among national staff. Signs of burnout are
described in Table 39.

Tbl. 39 Some signs of burnout 170


Cognitive/emotional

Physical

Behaviour

Difficulty in concentrating
Frequent bad moods
Feelings of anxiety or
generalised fear

Constant tiredness
Undiagnosed physical
complaints
Hyperventilation

Increased consumption of alcohol, cigarettes, drugs


Difficulty in relaxing or concentrating
Apathy
Aggression
Constant intellectualisation
Cynicism
Sleeping problems
Excessively demanding behaviour (e.g. for salary or of
different working conditions)
Constant talking

Each project must have a burnout prevention policy and its own Helping the Helpers system
for national staff. Burnout management is essential and mainly focuses on prevention. It involves:
Task management: job rotation of psycho and socio tasks, and case diversification;
Professional growth: clinical supervision, and on-going training;
Team management: team work, regular team meetings, regular social events, planned holidays,
and regular pay;
Psychological support when required: a structure of peer support, and a formalised Helping
the Helpers system.
Someone, preferably outside the organisation should provide psychological support to the
national staff. However, when this is not possible the expatriate mental health worker should
provide psychological care.
Expatriate staff have access to two forms of care.Team members can give social and technical
support. Specific technical advice is available from the medical line manager and technical
advisors from the headquarters. If the mental health expatriate needs personal support the care
can be provided by the organisations psychosocial care unit.

PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

111

Tbl. 40 Elements of staff support

Staff support

Content

National staff burnout management

As a part of the job (combination of psychoand socio tasks, case


diversification),
Professional growth (group and individual clinical supervision training),
Organisational structure (team work, regular team meetings, regular social
events, planned holidays, regular pay)

National staff
Helping the Helpers

Peer Support
Psychological support (preferably external)

Expatriate

Team work
Technical support
Psychosocial Care Unit (Headquarters)

LOGISTICS
Medical as well as mental health projects depend heavily on logistics.Transport, communication
and security management are of vital importance, especially in projects serving a large
beneficiary population.
The creation of a silent space for counselling is another area in which logistics becomes involved
in psychosocial programmes. Understanding what people with psychosocial problems need (e.g.
confidentiality, privacy, quiet rooms) is essential.The counselling space should preferably be
located within the medical facilities.
In emergency contexts special attention should be given to the severely ill. Both a resting area
(day care) and special waiting area for clients is necessary.
Lastly, logistics are needed to organise community activities, distraction or education activities.

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PSYCHOSOCIAL AND MENTAL HEALTH INTERVENTIONS IN AREAS OF MASS VIOLENCE, 2005

DEFINITIONS

Anthropological tools can be used to gather detailed information about beneficiaries perspectives
on mental disorder (e.g. causation and symptomology), local health management strategies for instance
religious healing, herbalism and witchcraft, and expected outcomes of psychosocial interventions.
Avoidance is a common reaction following a traumatic experience whereby an individual forgets,
ignores, denies information or painful recollections about the traumatic event. Avoidance is generally
a temporary response and a normal part of the coping process. If it becomes a habitual reaction or
permanent state, avoidance can impede both the coping process and healing.
Anxiety disorder is a generalised term that refers to a group of psychological disorders characterized
by excessive tension and worry. Anxiety disorders may be linked to specific situations or involve general
states, definable by the DSM-IV.171
Burnout is a combination of tiredness, tagycardia, nausea, high blood pressure and psychological
complaints such as restlesness, sleep disturbances and emotional exhaustion. It is the result of a long
process that eventual ends in total collapse of the person.
Beneficiary refers to a member of the target population that is receiving humanitarian medical
assistance within a specified intervention area; the term is used when discussing management aspects
of a programme.
Client refers to a beneficiary who has been admitted into a mental health or psychosocial programme
to receive care, and is involved in a therapeutic relationship with a counsellor/mental health practitioner.
The client is not called patient (as in the medical setting) because psychosocial or mental health support
is not necessarily restricted to medical disorders.
Clinical supervision is a contracted activity; it is a shared reflection on a client case between the
clinical supervisor, often the expatriate, and the counsellor (also referred to as the supervisee).The focus
of reflection is on the supervisees work in order to give the supervisee more cognitive, more emotional
and more independent perspective on his clients case.172
Cognitive-behavioural oriented brief-therapy See Cognitive Behaviour Therapy. Brief refers to
a limited number of sessions (6 to maximum 12).
Cognitive Behaviour Therapy is an action-oriented form of psychotherapy that assumes that
maladaptive, or faulty, thinking patterns cause counter-productive behaviour and negative emotions.
Treatment focuses on changing an individual's thoughts (cognitive patterns) in order to modify his
behaviour and emotional state, and involves a collaborative effort between counsellor and client.
Clients are taught to view automatic thoughts (maladaptive cognitions) as hypotheses subject to
empirical validation, rather than as established facts.Therapy gives clients an active role in their healing
process and empowers them by providing them with skills and experiences that create adaptive thinking.173
Cognitive Behaviour Therapy is typically administered in an outpatient setting in either an individual or
group session. It is currently popular because of the relatively low number of treatment sessions and its
positive scientific effectiveness evaluation.

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Comprehensive health care approach assumes a holistic interpretation of the human being as
being physical, mental, social, spiritual and moral in nature. Definitions of health and disease are
understood not only in terms of traditional categories of physical and mental physiology, but also in
term of socio-cultural and religious worldviews.
Coping is a process in which the individual (or group) deals with situations by managing them
adequately without necessarily mastering them completely.174 After a traumatic experience, new
information needs to be processed, assimilated and integrated into a new worldview. According to
cognitive processing theories the two most common elements of the coping processes are intrusion
and avoidance.175
Counselling is a relationship in which a helper assists a client to understand himself and his problems
better. Where appropriate, the helper uses various strategies to clarify and expand the clients
understanding, to assist him to develop and implement strategies for changing how he thinks, acts,
feels so he can attain life-affirming goals.176
Counter-transference. See below for a definition of transference.
Cultural psychology is the study of the ways in which subject and object, self and other, psyche
and culture, person and context, figure and ground, practitioner and practice live together, require
each other, and dynamically, dialectically, and jointly make each other up. Psychological differences
are understood by virtue of the ways in which socio-cultural environments shape and affect
peoples responses.
Depression in moderate manifestations is a condition characterized by negative feelings about the self,
pessimism about the future, a general sense of inadequacy and a slowed activity rate. More extreme
forms involve withdrawal into the self, possible development of the sense of hopelessness and perhaps
delusions of guilt and inadequacy.Transcultural psychiatry emphasizes that local definitions of self affect
a clients experience of depression,xxx and how he expresses emotions and symptoms. Causes and
symptoms of depression therefore differ according to cultural context and behavioural norms.
Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard international
diagnostic classification system and coding reference for mental disorders. It contains categories, criteria,
and descriptions designed to assist the process of diagnosing individuals with mental disorders.The DSM
is intended for use by individuals who have appropriate clinical training.177
Diaries are qualitative tools used to validate information such as about the prevalence of symptoms,
reduction of social contacts from interviews.
Disassociation is a psychological coping mechanism that involves the disruption of cognitive functions
that are usually integrated, such as consciousness, memory, identity, or perception of the environment.
Disease refers to the way practitioners recast illness in terms of their theoretical models of pathology.178
Drop-out analysis involves the random selection of a number of people who previously received
counselling support, but who did not return follow-up appointments; this is followed by an interview
about their reasons for drop-out, current level of symptoms and complaints.

xxx The transcultural psychiatry concept self differs from the traditional Freudian one. It sees the self as culture-dependent (i.e. not a static ego) and
is constantly evolving parallel to changes in its socio-cultural environment.

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Emotion-focused coping is a process where tension aroused by a traumatic experience is reduced


through intra-psychic activity, such as denial or changing ones attitude.
Ethnopsychology is concerned with the investigation of mind, self, body and emotion within and
between cultures, emphasising the relativity of each to local (or indigenous) context.
Focus Group Discussion (FGD) is a qualitative information-collection tool. It involves facilitating
discussion about a predefined (and limited) topic among a selected group of beneficiaries.This is a
natural and relatively fast way to assess needs, to survey results and become familiar with local ways
of thinking, opinions, perceptions of the beneficiaries and suggestions for intervention.
Illness refers to the clients perception, experience, expression and pattern of coping with symptoms.
Because language, illness beliefs, personal significance of pain and suffering and socially learned ways of
behaving when ill are part of that process of mediation, the experience of illness (or distress) is always
a culturally shaped phenomenon.179
Insomnia is the inability to fall or stay asleep. Insomnia can be classified as transient (short term),
intermittent (on and off) and chronic (constant). Chronic insomnia is more complex and often results
from a combination of factors, including underlying physical or mental disorders.
Intrusion is a process whereby the survivor unconsciously re-lives a traumatic experience through
intrusive and emotionally upsetting recollections and symptoms like nightmares or flashbacks. It is a
normal part of the coping process and enables a survivor to re-evaluate and re-define his worldview.
If the intrusions persist longer than three months it is an indication of a mental disorder.180
Key informant interview is a qualitative tool for acquiring detailed information about beneficiaries
perspectives.There are several types of key informant interviews including: in-depth, individual or group
and case study interviews. Key informant interviews are obligatory in psychosocial assessments. Several
formats such as general interview, psychosocial consequences of violence and coping mechanisms can
be used.
Mapping is a qualitative technique used in the field during project assessments and interventions to
acquire detailed local information on several topics. Several techniques are used, including: participatory
mapping (to find out individual perception on certain issues e.g. social dynamics), social mapping (the
beneficiaries draw what inside or outside social resources are available), and hierarchy mapping (who is
in power and who is responsible for what).These environmental tools are helpful in the identification of
social, spiritual and moral resources and resilience mechanisms.
Mental health consists of a series of different psychological processes that enhance a persons
psychological, emotional and social functioning. Definitions of mental health vary across cultures and
between individuals.
Mental health disorders are disturbances in the biological and/or psychological functioning.They are
diagnosed according to a standard system of criteria that allows a generally accepted definition of the
condition.The most frequently used diagnostic systems are the DSM IV181 and ICD-10.182 The definition
of mental health problems is culturally defined. Consequently various categorical systems can be
described. However, it is universally accepted that mental health problems are medical.
Moral health is determined by a set of written or unwritten rules constituting what is good or bad

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behaviour, accepted and unaccepted emotions or cognitions by a group of people. Mass violence can
have serious effects on these individual and group values.They can affect peoples judgments, shatter
beliefs about trust and the benevolence of the people and destroy community norms of generally
acceptable behaviour, emotions and cognitions. Definitions of what is morally good or bad, and
therefore healthy or unhealthy, are culture-specific, and defined by local systems.
Outcome indicators measure, in relation to a stated project purpose, the results of the combined
project activities including those of others.183
Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can occur if people are
unable to integrate their traumatic experience in their present life. PTSD is marked by clear biological
changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in
conjunction with related disorders such as depression, substance abuse, problems of memory and
cognition, and other problems of physical and mental health. PTSD can be diagnosed three months
from the traumatic incident. Before this most of the problems are regarded as part of the normal
coping process.
Problem-focused coping is a style of coping in which a person or group focuses all energy and
resources to solve the stress-creating problem. It is a practical approach, and the opposite of emotionfocused coping.
Process indicators measure the extent to which activities have been undertaken designed to achieve
a stated specific objective.
Psychological anthropology focuses on behaviour (performance) such as rituals, folk tales, games
and art, kinship or religions etc., and has as its underlying assumption that all humans have an inherent
central processing mechanism, or a deep processing system (psychic unity).
Psychological package is the part of a psychosocial programme that focuses directly or indirectly
through the training of health staff on the problems of behaviour or personal emotions (e.g. fear,
despair), and thoughts.
Psychology assumes that humans have a central procession mechanism that is transcendent, abstract,
fixed and a universal property of the human psyche. It does not believe in a context-free, meaning-free
stimulus of thought and or action. It seeks to differentiate (isolate) central processing functions and
development of the mind (e.g. discrimination, categorisation, memory, emotions, behaviour learning,
motivation, inference, etc.).184
Psychosis is a mental disorder sufficiently severe to result in personality disorganisation and a loss of
contact with reality.
Psychosocial health indicates the presence of life or personal problems that undermine daily normal
functioning.The definition of what constitutes normal varies cross-culturally and between individuals.
Psychosocial illnesses are conditions of not well being, common in the community.The relationship
between psychological and social effects is dynamic, mutual and ongoing. Psycho refers to psychological,
that means problems of behaviour or needs of personal emotions, thoughts and feelings like fear and
despair. Social refers to the interaction between the individual and a larger group such as family,
community and/or its environment (physical, moral, spiritual).That means, for instance, problems or

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needs that are related to displacement, refuge, suppression, poverty, domestic violence, marital problems,
child abuse etc. Social problems can easily affect the psychological status of the individual. Psychological
problems can affect the individuals social (e.g. interpersonal relations) well being.185
Psychosocial questionnaires are structured interviews used for the large-scale appraisal of
psychosocial needs in closed (camp) and open (community) settings.They provide insight into the
events through exposure or witnessing, the psychological impact (the standardised impact of event scale
IES), the prevalence of specific health complaints and stress (General Health Questionnaire 28, GHQ
28) and some questions on knowledge, attitude, and self-help mechanisms.186
Qualitative assessment instruments provide subjective data about individuals or groups in a
beneficiary population, and include the following: literature reviews, focus group discussions, key
informant interviews, structured or checklist observation, diaries, mapping, anthropological tools,
workshops and dictionaries.
Quantitative assessment instruments provide objective data about individuals/groups in a
beneficiary population, and include the following: basic health care data and mental health statistics,
psychosocial questionnaires, symptom checklists, and self-completion questionnaires.
Rape includes any sexual act or penetration, of any kind whatsoever, committed on another person by
means of violence, compulsion, threat or surprise. Rape is commonly used as a weapon of war in
conflict settings.187
Resilience is the capacity to restore a new balance when the old ones are challenged or dysfunctional.
Resilience is defined through physical, mental, social, spiritual and moral systems.The popular translation
of resilience: the ability to bounce back, is inadequate because after traumatic experiences a new
balance (or worldview) needs to be established, rather than old ones restored.
Self-completion questionnaires are quantitative instruments containing short open-ended
questions used to obtain quick information about sensitive subjects.
Social health involves the ability to engage in social interaction and/or be an active member of a
community.The ability to mobilise appropriate social support is equally important to having a social
network. Both are measures for social health.
Social package is the part of the psychosocial programme that focuses on the provision of practical
support, community education, mobilisation and stimulation activities, the aim of which is to enhance the
mutual interaction between the individual and a larger group such as family and community or his
environment (physical, moral, spiritual).
Somatisation involves the translation of emotions such as distress or sadness into physical signs and
symptoms. Somatic symptoms serve as cultural idioms of stress in many ethnocultural groups and, if
misinterpreted by the mental health specialist, counsellor or medical professional, may lead to
unnecessary diagnostic procedures or inappropriate treatment.188
Spiritual health. Spirituality has been defined in various ways, ranging from a New Age understanding189
of spirituality to the criteria defined by the Spiritual Experience Index.190 The term spirituality was
preferred to the term religion because it describes a wider range of religious experiences outside

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organised groups. Nevertheless, spirituality and religion are inseparable because spirituality is an essential
element of religious life.191
Spirituality presupposes the existence and experience of spirit, something ego-transcendental; something
we may call divine power. Spirituality can be defined as the ability of the human mind to relate to
transcendental power.192
Traumatic experiences can lead to a major shift in the individuals internal belief systems, either as
powerful sources of motivation or destruction. Spiritual health goes beyond religious affiliation and the
belief in God. It is a state of inspiration, reverence, awe, meaning and fulfilled purpose; a state of
harmony with the universe and questions about the infinite. Spiritual health or disorder becomes
noticeable in times of emotional stress, physical (and mental) illness, loss, bereavement and death.193
Performing rituals (especially burial) and visiting places of contemplation or worship are powerful tools
to promote spiritual health.
Stressful events and traumatic stress have not been distinguished successfully yet.The
qualification of an event being traumatic or stressful is bound individually. Events that do not involve
extreme stress (immediate survival) can be perceived as challenging by some or as threatening by
others.Traumatic stress is often associated with wars, captivity, torture, disasters and racial
discrimination.194
Structured or checklist observation is a qualitative tool for rapidly acquiring information about
beneficiaries and includes: direct observation, walking around and clinical observation. This tool is a
good method to see whether people actually do what they say in interviews.
Stupor is defined as mutism and akinesis: a client appears alert because of eye movements, but is
unable to initiate speech or action. Consciousness is clouded and attention for environmental stimuli
is diminished. Anxiety and neurological symptoms are absent; respiration, pulse and blood pressure
are stable.
Supplementary Feeding Programme (SFP) provides nutritional support (in the form of daily
wet rations or weekly dry rations) to moderately malnourished individuals.
Symptom checklists (HSCL 25, IES, GHQ 28) are quantitative instruments used to assess the
prevalence of psychosocial stress symptoms in a population. Symptom checklists are in general not
validated for non-Western cultural environments.195
Therapeutic Feeding Programme (TFP) provides intensive medical and nutritional support to
severely malnourished individuals.Treatment is given under clinical supervision over a two-week period.
The Stress Model is used to explain how social environment influences personality development and
the origin of mental and other disorders. Serious perturbations, or stressors, disturb an individuals
psychological equilibrium and cause him/her to initiate coping activities to restore their mental health.
Mental disorders and distress may arise from the interaction between the stressor (e.g. a life changing
event) and the individual who perceives the event as stressful, threatening, or uncontrollable, and
worsen in the absence of adequate social support and other coping responses.196
Traditional medicines are those diverse health practices, approaches, knowledge and beliefs
incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual technologies and
exercises applied singularly or in combination to maintain the well-being of the client, as well as to treat,

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diagnose or prevent illness.197


Transcultural Psychiatry combines anthropological information about culture and social groups
with epidemiological and psychiatric studies of the aetiology of health and illness. It employs the
anthropological assumption that patterns of thought and behaviour are learned through ones cultural
environment.Therefore while people experience the same types of psychiatric and psychological
disorders worldwide, they express mental disorders in varying ways cross-culturally.
Transference is the process by which a clients outside relationships strongly influence the nature of
his or her relationship with the counsellor (or therapist). In transference, people ascribe characteristics
of people who have significantly shaped their development to new acquaintances (e.g. the counsellor).
Counter-transference refers to the same phenomenon in the counsellor (or therapist) who, however, is
trained or clinically supervised to recognise it and prevent it from adversely affecting the therapeutic
relationship.198
Traumatic event involves a confrontation with helplessness and death, and a complete loss of
control. Definitions of what constitutes a trauma are often subjective and culture-bound, but generally
include a direct encounter with or witnessing of life-threatening events and violent personal assaults.
By nature, a traumatic event is sudden, unexpected and overwhelming.The very essence of an acute
traumatic stress reaction is that it hampers the critical processes of survival and adaptation.
Triangulation is the use of different sources and methods to check validity of certain information,
or to identify the truth when beneficiary information is conflicting. It is a useful technique to analyse
a populations severity of trauma, conflict related health needs, their resilience mechanisms and available
resources to determine programme responses (response intensity).
Voluntary Counselling and Testing (VCT) combines psychosocial support and the provision of
information to people who are considering having themselves tested for HIV/AIDS (pre-test) or those
who have been tested and need to know the result (post-test). If the client is tested positive the VCT
is often the first point of entry for a client into an HIV/AIDS programme.
Vulnerability in the context of traumatic experiences refers to an individuals ability to cope with
trauma.Vulnerability is defined by three major factors: Events related to the trauma (e.g. intensity,
life danger, extent of physical injury, number of experiences, duration, proximity, preparation); personal
related attributes (e.g. pre-trauma experiences, coping style) and the recovery environment (socioeconomic setting, poverty, marginalisation). In the context of mental health and psychosocial
programmes, vulnerability is further defined in terms of morbidity (e.g. the presence of symptoms),
mortality (e.g. suicide), access to care, lack of dignity and specific conditions that increase vulnerability
(e.g. being in a psychiatric institutions).
Witnessing (also referred to within MSF as tmoignage) consists of the presence of volunteers
among people in danger. Witnessing is motivated by a concern for the fate of fellow human beings and
a willingness to be at their side and listen to them, care for them at their bedside, and report on their
behalf about their situation.199

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INFORMATION RESOURCES WEBSITES

Human rights
Amnesty International
www.amnesty.org
Human Rights Watch
www.hrw.org
International Societies, NGOs and Associations
Alertnet
www.alertnet.org
American Psychology Association
www.apa.org
Colegio Oficial de Psiclogos (Espaa)
www.cop.es/cop
Center for International Disaster Information (CIDI)
www.cidi.org
ERCOMER - The European Research Centre on Migration and Ethnic Relations
www.ercomer.org
Geneva Initiative for Psychiatry
www.geneva-initiative.org
Interaction
www.interaction.org
International Association for Cross Cultural Psychology
www.iaccp.org
International Centre for Migration and Health (ICMH)
www.icmh.ch
International Society for Traumatic Stress Studies
www.istss.org
Pan American Health Organisation
www.paho.org
Red Cross and Red Crescent Movement
www.icrc.org
Refugee Studies Centre
www.rsc.ox.ac.uk
Relief Web (UN website providing information to humanitarian relief organisations)
www.reliefweb.int

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Sphere Project
www.sphereproject.org
UN SYSTEM
United Nations
www.unsystem.org
UNAIDS
www.unaids.org
United Nations Children's Fund
www.unicef.org
United Nations High Commissioner for Refugees
www.unhcr.ch
United Nations Development Fund for Women
www.unifem.org
United Nations Development Programme
www.undp.org
United Nations Population Fund
www.unfpa.org
OCHA IRIN
www.irinnews.org
WHO
World Health Organisation
www.who.int/en
www.who.int/mental_health/media/en/investing_mnh.pdf
www.cvdinfobase.ca/mh-atlas (maps, tables and charts including country profiles on mental health)
World Organisation Against Torture
www.derechos.org/omct
World Association for Psychosocial Rehabilitation (WAPR)
www.candido.org.br
World Federation For Mental Health Homepage
www.wfmh.com

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Resources in the field of Mental Health


All About Counseling.Com
www.allaboutcounseling.com
David Baldwins Trauma Information page
www.trauma-pages.com
Center for International Disaster Information (CIDI)
www.cidi.org/articles/paho.htm
Cepda training manuals
www.cedpa.org/cgi/cedpastore/publist.html?id=anwwygm5
CERTI Toolkit
www.certi.org/publications/publications.htm
Cross cultural assessment
www.certi.org/publications/policy/cross-cultural-10.htm
Dictionary on Mental Health
www.shef.ac.uk/~psysc/psychotherapy
Guidelines for crisis interventions in psychiatry
www.mhfa.com.au
International Organisation of Migration
www.iom.int
International Society of Traumatic Stress Studies: training guidelines
www.istss.org/terrorism/professionals.htm
Internet Mental Health
www.mentalhealth.com
National Institute of Mental Health
www.nimh.nih.gov/publicat/massviolence.pdf
National Mental Health Information Center
www .mentalhealth.org/ cornerstone/index.cfm
New South Wales Institue of Psychiatry; education provider
www.nswiop.nsw.edu.au
Mental Health Help
www.mentalhelp.net
Oxford Refugee Studies, Centre for International Health (CIHS)
Queen Margaret College: The refugee experience
earlybird.qeh.ox.ac.uk/rfgexp/rsp_tre/welcome.htm
Psychosocial working group
www.forcedmigration.org/psychosocial
Psicquiatria resources
www.psiquiatria.com

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Psychiatric care and diseases


www.who.int/msa/mnh/ems/primacare/edukit
UNICEF Education in the Programme Division:
www.unicef.org/girlseducation/files/vol12nov98.pdf
United Nations High Commissioner for Refugees
Draft Guidelines for the Evaluation and Care of Victims of Trauma and Violence
www.hprt-cambridge.org/Layer3.asp?page_id=23
US Department of Health and Human services
Risk communication guidelines
www.riskcommunication.samhsa.gov/RiskComm.pdf
Treatment choices in psychological therapies and counselling (user friendly on all
counselling problems and mental health disorders)
www.dhigov.uk/home/fs/en
Red Cross Resources
www.rhrc.org/resources/gbv
www.ifrc.org/docs/pubs/health/chapter12.pdf
www.ifrc.org/cgi/pdf_pubshealth.pl?bestpractices.pdf
WHO
www.who.int/mental_health/prevention/mnhemergencies/en
Navigators
Healthgate
www.healthgate.com
Medscape
www.medscape.com
Info on bibliographical documentation - Anthropology - Sociology
Annual Review of Sociology On Line
www.annurev.org
Anthropology Resources on the Net
www.nitehawk.com/alleycat/anth-faq.html
Interagency Network for Education in Emergencies
www.ineesite.org
International Society of Traumatic Stress Disorders
Pilot data based on Post Stress Traumatic Disorder
www.istss.org
Literature about the consequences of war
www.gevolgenvanoorlog.nl

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Journals
American Psychological Society
www.psychologicalscience.org/journals
British Medical Journal www.bmi British Medical Journal
bmj.bmjjournals.com
International Journal of Psychosocial Rehabilitation
www.psvchosocial.com
Journal of American Medical Assocition (JAMA)
jama.ama-assn.org
NEJM
content.nejm.org
Psychiatric Rehabilitation Journal
www.bu.edu/pri/

Grey Literature
Humanitarian Information Network (HIN)
www.reliefweb.int
www.reliefweb.int/hin/lib.htm
Psychosocial working group
www.forcedmigration.org/psychosocial/
Special topics
Caring for Carers
Caring for Carers. UNAIDS, 2000
www.unaids.org
Physician Stress and Burnout. TMA, 2003
www.texmed.org/cme/phn/psb/burnout.asp

Chemical, Biological Warfare


www.who.int/csr/delibepidemics/preparedness/cbw/en

Community education
Manual for Health Communication. Centre for Health Promotion,
University of Toronto, March, 2002
www.thcu.ca

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HIV/AIDS
VCT The impact of Voluntary Counselling and Testing. A global review of the
benefits and challenges. UNAIDS, 2001
www.emro.who.int/asd/backgrounddocuments/egy0703/ImpactVCT.pdf
CDC
www.cdc.gov/mmwr/preview/mmwrhtml/mm5146a5.htm
Voluntary Counselling and Testing (VCT). UNAIDS Technical Update, May 2000
www.emro.who.int/asd/backgrounddocuments/egy0703/VCTTechnicalUpdate.pdf
Psychotropic drug and ARV interaction
www.medsape.com

Sexual Violence
Sexual violence guidelines
www.rhrc.org
Torture
Examining Asylum Seekers
www.phrusa.org/campaigns/asylum_network/manual.html

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